Methods of improving myocardial performance in fontan patients using udenafil compositions

ABSTRACT

The present invention relates generally to the field of using udenafil or a pharmaceutically acceptable salt thereof in patients who have undergone the Fontan operation.

CROSS REFERENCE TO RELATED APPLICATIONS

The present invention claims priority to U.S. Provisional PatentApplication No. 62/036,506, filed on Aug. 12, 2014, and U.S. ProvisionalPatent Application No. 62/186,132, filed on Jun. 29, 2015, thedisclosures of which are specifically incorporated herein by reference.

FIELD OF THE INVENTION

The present invention relates generally to the field of usingphosphodiesterase E5 (PDE5) inhibitors in patients who have undergonethe Fontan operation. In particular, the PDE5 inhibitor is udenafil or apharmaceutically acceptable salt thereof.

BACKGROUND OF THE INVENTION 1. Background Regarding the Fontan Procedure

The Fontan procedure, or Fontan/Kreutzer procedure, is a palliativesurgical procedure for children born with functional single ventriclecongenital heart disease. The Fontan operation was designed to provideblood flow in series to the pulmonary and systemic circulation withoutthe requirement for a right ventricular pumping chamber. The operationallows systemic venous blood to flow directly into the pulmonarycirculation on the basis of a single ventricular impetus through thearteries, capillaries, and systemic venous system. This arrangement hasimproved life expectancy for patients with single-ventricle andpulmonary-outflow obstruction compared with previous arterial shunts.

The operation, which creates a total cavopulmonary connection, separatesthe systemic and pulmonary circuits and eliminates both hypoxemia andventricular volume overload. However, following the Fontan operationthere is no ventricular pump to propel blood into the pulmonaryarteries. Instead, blood returns to the lungs via passive flow from thesystemic veins. This results in a circulation characterized by elevatedcentral venous pressure, abnormal pulmonary vascular resistance, and achronically low cardiac output. Over time, these inherentcharacteristics of Fontan physiology result in a predictable, persistentdeterioration of cardiovascular efficiency, as marked by a progressivedecline in exercise performance that begins after puberty. This declinein exercise capacity correlates with an increase in symptoms fromcardiovascular dysfunction and may result in the need forhospitalization, escalation of heart failure management, or transplant.

Those with the Fontan circulation do not have ‘normal’ heart physiologyor functioning. Two major complications that might have many“downstream” effects are the following effects on increasing(“hypertension”) and decreasing (“hypotension”) blood pressure dependingupon its location (veins or arteries). First, with Fontan circulation,there is “systemic venous hypertension”, which means that the bloodpressure in the veins (blood going back to the heart) in the body ishigher than in individuals with normal heart function (not Fontancirculation). There are many negative consequences that may be caused bysystemic venous hypertension (congestive heart failure, edema orswelling, dysfunction of the liver, potentially protein-losingenteropathy) that are basically related to the distribution of fluids inthe body. A second complication is “pulmonary arterial hypotension”where the blood pressure in arteries going towards or in the lungs(hence pulmonary) is lower than in individuals with normal heartfunction. There are also a number of negative consequences associatedwith pulmonary arterial hypotension such as cyanosis (blue lips) or lackof exercise capacity. Many of the subsequent medical conditions anddeaths that follow the Fontan procedure (either in the short- orlong-term) are thought to originate from this change in systemic andpulmonary blood pressure.

The long-term effects of marked single-ventricle preload and inefficientoxygenation via an arterial shunt rarely allow survival beyond thesecond or third decade of life. Uniformly lethal four decades ago, thenewborn with single ventricle type congenital heart disease in 2010 isnow not only likely—but expected—to survive. However, as these childrenhave grown into adolescence and adulthood, it is clear that there aresignificant limitations to this strategy. While lifesaving, theFontan/Kreutzer operation results in profound physiological disturbanceswith very serious consequences. Pervasive abnormalities of multipleorgan systems are affected as time goes on. Realistically, it isunlikely that patients will survive into their third or fourth decadesof life untouched by some potentially life-threatening complication.Thus, there is a clear need to identify treatments that may amelioratethe dysfunctional state of the Fontan operation. This is particularlytrue given the increase in the prevalence of the Fontan procedures:remarkably, the Fontan operation has become the most common procedureperformed for congenital heart disease after the age of 2 years. W. M.Gersony, Circulation, 117: 13-15 (2008).

Multiple studies looking at the results of the Fontan operationdemonstrate a decrease in survival beyond 15 years after surgery. Anongoing significant risk of death with continuous attrition is present,regardless of surgical type of cavo-pulmonary connection. In anotherstudy looking at morphologically single left ventricle after Fontansurgery, results showed that odds are 1 out 4 that a child after Fontanwill be dead by the time he or she reaches their late 20s. J. Rychik,“Forty Years of the Fontan Operation: A Failed Strategy,” PediatricCardiac Surgery Annual, 96-100 (2010).

Given the increased life span for Fontan patients, researchers havesought out medical therapies to address the side effects of the Fontansurgery. In particular, children and young adults with single-ventriclephysiology have abnormal exercise capacity after the Fontan operation.Strategies targeted toward improving cardiac output and reducing centralvenous pressure will improve their overall well-being and mitigateagainst the impact of this deleterious physiology.

In one study, the PDE5 inhibitor sildenafil was found to significantlyimprove ventilatory efficiency during peak and submaximal exercise.There was also a suggestion of improved oxygen consumption at theanaerobic threshold in 2 subgroups. These findings suggest thatsildenafil may be an important agent for improving exercise performancein children and young adults with single-ventricle physiology after theFontan operation. Goldberg et al., Circulation, 123: 1185-1193 (2011).

Later studies verified that sildenafil increased ventricular systolicelastance and improved ventriculo-arterial coupling in patientspalliated with Fontan circulation. Short-term sildenafil was welltolerated in most of the patients with only minor side effects.Shabanian et al., Pediatr. Cardiol., 34(1): 129-34 (2013). The structureof sildenafil is shown below:

In addition, a preliminary study assessed the short-term effects of thePDE5 inhibitor tadalafil on the hemodynamic response to exercise andexercise capacity in patients with Fontan circulation. Seehttp://clinicaltrials.gov/ct2/show/record/NCT01291069. Short termtherapy with once daily dosing of tadalafil improved ventilatoryefficiency and oxygen saturation, but exercise capacity was unchanged inyoung Fontan subjects, similar to published sildenafil results. Menon etal., Circulation, 128: A16024 (2013). The chemical structure oftadalafil is shown below:

For optimal effectiveness, the PDE5 inhibitors sildenafil or tadalafilwould need to be given long term to Fontan patients to delay or preventthe onset of failing Fontan circulation. Fontan surgery produces chronicconditions; short term treatment is unlikely to address mortalityassociated with children having a Fontan surgery when they are anadolescent or adult. This is particularly true as when Fontan failuresets in, there is an inexorable hemodynamic and functional decline inthe patients leading to death or cardiac transplantation. The earlyexperience with transplantation in patients with Fontan circulation wasof high operative mortality and morbidity. The assumption that if apatient survives with a Fontan circulation, then the PVR is low enoughfor the right ventricle of the graft after cardiac transplantation wasfound to be incorrect in the early experience of Fontan transplants.

While both sildenafil and tadalafil are known to have undesirable sideeffects, pulmonary arterial hypertension (PAH) patients switched fromsildenafil to tadalafil were found to show significantly differentoxygen saturation, significantly different oxygen saturation after a6-minute walk test, and significantly different distances walked, thusshowing that PDE5 inhibitors are not interchangeable when used to treatheart or cardiovascular conditions. Sabri et al., Pediatr Cardiol.,35(4):699-704 (2014).

II. Background Regarding PDE5 Inhibitors and Udenafil

PDE5 is a cyclic guanosine-3′,5′-monophosphate (cGMP)-specificphosphodiesterase belonging to a class of phosphodiesterases whichregulate various cell functions by catalyzing the hydrolysis of thesecond messenger molecules (cGMP) and cyclicadenosine-3′,5′-monophosphate (cAMP). Boolell et al., Int'l J. Impot.Res., 8:47 (1996). Because PDE5 is present in the arterial wall smoothmuscle within the lungs, PDE5 inhibitors have been explored for thetreatment of pulmonary hypertension, a disease in which blood vessels inthe lungs become overloaded with fluid, usually as a result of failureof the right ventricle of the heart.

Udenafil is a drug used in urology to treat erectile dysfunction. Itbelongs to a class of drugs called PDE5 inhibitors, which also includessildenafil, tadalafil, and vardenafil. Typical doses are 100 and 200 mg.Udenafil is available in Korea, Russia, and Philippines; in the UnitedStates, it is not approved for use by the U.S. Food and DrugAdministration.

The Fontan procedure is palliative, not curative. But in many cases itcan result in normal or near-normal growth, development, exercisetolerance, and good quality of life. In 20/30% cases, patients willeventually require heart transplantation.

Modifications in the Fontan operative model was one of the early stepsin improving outcome. Use of fenestration, staging of Fontan completionand better perioperative management have led to a significant drop inmortality rates in the current era. Despite this, there is lateattrition of patients with complications such as arrhythmias,ventricular dysfunction, and unusual clinical syndromes ofprotein-losing enteropathy (PLE) and plastic bronchitis. Management offailing Fontan includes a detailed hemodynamic and imaging assessment totreat any correctable lesions such as obstruction within the Fontancircuit, early control of arrhythmia and maintenance of sinus rhythm,symptomatic treatment for PLE and plastic bronchitis, manipulation ofsystemic and pulmonary vascular resistance, and Fontan conversion ofless favorable atriopulmonary connection to extra-cardiac totalcavopulmonary connection with arrythmia surgery. Cardiac transplantationremains the only successful definitive palliation in the failing Fontanpatients. However, cardiac transplantation is not a perfect solutionbecause the Fontan circulation has already wreaked havoc in the bodysuch as negatively affecting hepatic or kidney function, thus patientswith Fontan circulation may still be in poor shape even after a hearttransplant.

There is a need in the art for improved therapies relating tocomplications or side effects of the Fontan procedure with the goal ofincreasing the life span of Fontan patients, and avoiding or delayingthe need for cardiac transplantation. There is also a need in the artfor improved therapies to delay the onset of cardiac failure or toimprove the quality of life for patients who have had the Fontanprocedure. The present invention satisfies this need.

SUMMARY OF THE INVENTION

In one embodiment, the invention is directed to methods of treating,preventing, or minimizing conditions, symptoms, or side effectsassociated with a subject who has previously had a Fontan procedure. Inparticular, the methods of the invention are directed the use ofudenafil or a pharmaceutically acceptable salt thereof in singleventricle adolescent patients that have undergone the Fontan procedurefor the amelioration of associated acute symptoms and chronic symptomdevelopment. The method comprises administering a therapeuticallyeffective amount of a PDE5 inhibitor to the patient, where the PDE5inhibitor is udenafil or a pharmaceutically acceptable salt thereof.

In one embodiment, the invention is directed to a method of improvingcardiac output in a patient who has had a Fontan procedure. The methodcomprises administering a therapeutically effective amount of a PDE5inhibitor to the patient, where the PDE5 inhibitor is udenafil or apharmaceutically acceptable salt thereof.

In another embodiment, the invention is directed to a method ofdecreasing pulmonary vascular resistance in a patient who has had aFontan procedure. The method comprises administering a therapeuticallyeffective amount of a PDE5 inhibitor to the patient, where the PDE5inhibitor is udenafil or a pharmaceutically acceptable salt thereof.

In yet another embodiment, the invention is directed to a method ofimproving exercise capacity in a patient who has had a Fontan procedure.The method comprises administering a therapeutically effective amount ofa PDE5 inhibitor to the patient, where the PDE5 inhibitor is udenafil ora pharmaceutically acceptable salt thereof.

In one embodiment, the invention is directed to a method of improvingmyocardial performance in a patient who has had a Fontan procedure. Themethod comprises administering a therapeutically effective amount of aPDE5 inhibitor to the patient, where the PDE5 inhibitor is udenafil or apharmaceutically acceptable salt thereof.

In an exemplary embodiment, the methods of the invention compriseadministering a therapeutically effective dose of udenafil, or apharmaceutically acceptable salt thereof, once a day to a patient.

In another embodiment, the methods of the invention compriseadministering a therapeutically effective dose of udenafil, or apharmaceutically acceptable salt thereof, twice a day to a patient.

In another embodiment, the patient is a pediatric patient of about 2 toabout 18 years of age. Treatment of adult patients are also encompassedby the methods of the invention.

In yet another embodiment, the invention is directed to improved methodsfor treating a patient who has had a Fontan procedure, wherein themethods show an improvement in patient compliance with a dosing scheduleof udenafil or a pharmaceutically acceptable salt thereof, as comparedto patients prescribed a non-udenafil drug.

In one embodiment, the invention is directed to improved methods fortreating a patient who has had a Fontan procedure, wherein the methodsof the invention result in fewer or less severe adverse events ascompared to conventional, methods of treating such patients. In anotherembodiment, the methods of the invention result in few, if any, seriousadverse events, moderate adverse events, or mild adverse events.

In another embodiment, the methods of the invention result in improvedVO2 at the patient's maximal effort as compared to VO2 at maximal effortin the absence of the methods of the invention (e.g., in the absence ofudenafil administration). For example, the improvement can be about 5,about 6, about 7, about 8, about 9, about 10, about 11, about 12, about13, about 14, about 15, about 16, about 17, about 18, about 19, about20, about 21, about 22, about 23, about 24, about 25, about 26, about27, about 28, about 29, or about 30% or greater as compared to VO2 atmaximal effort in the absence of the methods of the invention (e.g., inthe absence of udenafil administration).

In another embodiment, the methods of the invention result in improvedVO2 at the patient's anaerobic threshold as compared to VO2 at anaerobicthreshold in the absence of the methods of the invention (e.g., in theabsence of udenafil administration). For example, the improvement can beabout 5, about 6, about 7, about 8, about 9, about 10, about 11, about12, about 13, about 14, about 15, about 16, about 17, about 18, about19, about 20, about 21, about 22, about 23, about 24, about 25, about26, about 27, about 28, about 29, or about 30% or greater as compared toVO2 at maximal effort in the absence of the methods of the invention(e.g., in the absence of udenafil administration).

In another embodiment, the methods of the invention result in thepatient's blood pool MPI, or other disclosed measures of ventricularperformance, improving as compared to blood pool MPI, or other disclosedmeasures of ventricular performance in the absence of the methods of theinvention (e.g., in the absence of udenafil administration). Forexample, the improvement can be about 5, about 6, about 7, about 8,about 9, about 10, about 11, about 12, about 13, about 14, about 15,about 16, about 17, about 18, about 19, about 20, about 21, about 22,about 23, about 24, about 25, about 26, about 27, about 28, about 29, orabout 30% or greater as compared to blood pool MPI, or other disclosedmeasures of ventricular performance in the absence of the methods of theinvention (e.g., in the absence of udenafil administration).

In another embodiment, the methods of the invention result in thepatient's log of reactive hyperemia index, or another disclosed measureof vascular function, improving as compared to log of reactive hyperemiaindex, or another disclosed measure of vascular function, in the absenceof the methods of the invention (e.g., in the absence of udenafiladministration). For example, the improvement can be about 5, about 6,about 7, about 8, about 9, about 10, about 11, about 12, about 13, about14, about 15, about 16, about 17, about 18, about 19, about 20, about21, about 22, about 23, about 24, about 25, about 26, about 27, about28, about 29, or about 30% or greater as compared to log of reactivehyperemia index, or another disclosed measure of vascular function, inthe absence of the methods of the invention (e.g., in the absence ofudenafil administration).

Finally, in yet another embodiment, the methods of the invention mayresult in a characteristic pharmacokinetic profile. The pharmacokineticprofile can comprises a C_(max) between 300 and 700 ng/ml, or morespecifically, about 500 ng/ml; a T_(max) between 1 and 1.6 hr, or morespecifically, about 1.3 hr; an AUC_(τ) between 2550 and 4150 ng·hr/ml,or more specifically, about 3350 ng·hr/ml; and an AUC₀₋₂₄ between 5110and 8290 ng·hr/ml, or more specifically, about 6701 ng·hr/ml.

The foregoing general description and following detailed description areexemplary and explanatory and are intended to provide furtherexplanation of the invention as claimed. Other objects, advantages, andnovel features will be readily apparent to those skilled in the art fromthe following brief description of the drawings and detailed descriptionof the invention.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows the percentage of subjects who reported at least one,three, or five adverse events by treatment group.

FIG. 2 shows change in peak VO2 (ml/kg/min) at the maximum effort frombaseline (day 1) to the last visit (post-medication, day 5) by treatmentgroup, where a positive change indicates an improvement.

FIG. 3 shows peak VO2 at the maximum effort at baseline (day 1) and atthe last visit (post-medication, day 5) by treatment group, where apositive change indicates an improvement.

FIG. 4 shows change in VO2 (ml/kg/min) at anaerobic threshold frombaseline (day 1) to the last visit (post-medication, day 5) by treatmentgroup, where a positive change indicates an improvement.

FIG. 5 shows peak VO2 at anaerobic threshold at baseline (day 1) and atthe last visit (post-medication, day 5) by treatment group, where apositive change indicates an improvement.

FIG. 6 shows change in natural log of Reactive Hyperemia Index frombaseline (day 1) to the last visit (post-medication, day 5) by treatmentgroup. A positive change indicates an improvement.

FIG. 7 shows natural log of Reactive Hyperemia Index (RHI) at baseline(day 1) and at the last visit (post-medication, day 5) by treatmentgroup. A positive change indicates an improvement.

FIG. 8 shows change in blood pool MPI from baseline (day 1) to the lastvisit (post-medication, day 5) by treatment group. A negative changeindicates an improvement.

FIG. 9 shows blood pool MPI at baseline (day 1) and at the last visit(post-medication, day 5) by treatment group. A negative change indicatesan improvement.

FIG. 10 shows change in tissue Doppler MPI from baseline (day 1) to thelast visit (post-medication, day 5) by treatment group. A negativechange indicates an improvement.

FIG. 11 shows tissue Doppler MPI at baseline (day 1) and at the lastvisit (post-medication, day 5) by treatment group. A negative changeindicates an improvement.

FIG. 12 shows change in average isovolumic contraction from baseline(day 1) to the last visit (post-medication, day 5) by treatment group. Anegative change indicates an improvement.

FIG. 13 shows average isovolumic contraction at baseline (day 1) and atthe last visit (post-medication, day 5) by treatment group. A negativechange indicates an improvement.

FIG. 14 shows change in average isovolumic relaxation from baseline(day 1) to the last visit (post-medication, day 5) by treatment group. Anegative change indicates an improvement.

FIG. 15 shows average isovolumic relaxation at baseline (day 1) and atthe last visit (post-medication, day 5) by treatment group. A negativechange indicates an improvement.

FIG. 16 shows individual concentration time curves stratified by dosingregimens of (A) 37.5 mg q24h, (B) 37.5 mg q12h, (C) 87.5 mg q24h, (D)87.5 mg q12h, and (E) 125 mg q24h.

FIG. 17 shows concentration time concentration profiles of udenafil instudy subjects. The solid line represents the observed data, the dashline stands for the predicted data for the second dose of the day for 12hour regimens. Data are represented as mean+/−standard deviation.

FIG. 18 shows a comparison of Cmax among various dosing regimens. Thebox and whisker plot showed 10-90 percentile and range of observationswith middle line representing median value of a dosing regimen.Significant difference: 37.5 mg q24h vs 87.5 mg q12h, p<0.001; 37.5 mgq24h vs 125 mg q24h, p<0.001; 37.5 mg q12h vs 87.5 mg q12h, p<0.001;37.5 mg q12h vs 125 mg q24h, p<0.01; 87.5 mg q24h vs 87.5 mg q12h,p<0.05.

FIG. 19 shows a comparison of (A) AUC_(τ) and (B) AUC0-24 among variousdosing regimens. The box and whisker plot showed 10-90 percentile andrange of observations with middle line representing median value of adosing regimen. Significant difference: A) 37.5 mg q24h vs 87.5 mg q12h,p<0.001; 37.5 mg q24h vs 125 mg q24h, p<0.001; 37.5 mg q12h vs 87.5 mgq12h, p<0.01; 37.5 mg q12h vs 125 mg q24h, p<0.01; B) 37.5 mg q24h vs87.5 mg q12h, p<0.001; 37.5 mg q24h vs 125 mg q24h, p<0.01; 37.5 mg q12hvs 87.5 mg q12h, p<0.001; 87.5 mg q24h vs 87.5 mg q12h, p<0.001; 87.5 mgq12h vs 125 mg q24h, p<0.001.

FIG. 20 shows a comparison of A) CL/F and B) V/F among various dosingregimens. The box and whisker plot showed 10-90 percentile and range ofobservations with middle line representing median value of a dosingregimen. Significant difference: A) 37.5 mg q24h vs 87.5 mg q12h,p<0.05; B) 37.5 mg q24h vs 87.5 mg q12h, p<0.01.

FIG. 21 shows DV (observed concentrations) versus subject ID.

FIG. 22 shows time (hours) versus subject ID.

FIG. 23 shows DV (observed concentrations) versus time after dose (TAD).

FIG. 24 shows DV (observed concentrations) versus time (hours).

FIG. 25 shows individual visual plots (SID 1-12) with variation betweenobserved concentration (DV) vs predicted concentration (PRED) andindividual predicted (IPRED) error vs time (h).

FIG. 26 shows individual visual plots (SID 13-24) with variation betweenobserved concentration (DV) vs predicted concentration (PRED) andindividual predicted (IPRED) error vs time (h).

FIG. 27 shows individual visual plots (SID 25-30) with variation betweenobserved concentration (DV) vs predicted concentration (PRED) andindividual predicted (IPRED) error vs time (h).

FIG. 28 shows a summary of average plasma concentration per time pointfrom pharmacokinetic studies of udenafil in Fontan's patients. Data areshown as mean+/−standard deviation.

FIG. 29 shows non-compartmental analysis of udenafil in Fonatn'spatients stratified by dosing regimens. Data are shown asmean+/−standard deviation.

FIG. 30 shows a goodness of fit plot of observed data versus predicteddata (DV vs. PRED).

FIG. 31 shows a goodness of fit plot of observed data versus individualpredicted data (DV vs. IPRED).

FIG. 32 shows a goodness of fit plot of observed data versus predicteddata (DV vs. PRED) of the final model.

FIG. 33 shows a goodness of fit plot of observed data versus individualpredicted data (DV vs. IPRED) of the final model.

FIG. 34 shows characteristic Fontan physiology.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 1. Fontan Physiology

The Fontan physiology is the definitive palliation for those classes ofcongenital heart defects that share the common feature of a functionalsingle ventricle. They include defects that result in hypoplastic leftor right ventricles. Usually through a series of 2 or 3 operations, thesystemic and pulmonary circulations are separated to eliminate themixing of oxygenated and un-oxygenated blood. This is accomplished bydirectly attaching the superior and inferior vena cavae to the pulmonaryarteries. This results in a physiology that works as follows: (1) thesingle systemic ventricle pumps oxygenated blood out the aorta to thebody's systemic vascular bed. (2) Next, the systemic venous blood thenreturns by the vena cavae and flows passively through the pulmonaryvascular bed without the aid of a sub-pulmonary ventricle. (3) Finally,oxygenated blood returns to the common systemic atrium and the cycle isrepeated. This anatomy is illustrated in FIG. 34.

The Fontan operation, which creates a total cavopulmonary connection,separates the systemic and pulmonary circuits and eliminates bothhypoxemia and ventricular volume overload. However, following the Fontanoperation there is no ventricular pump to propel blood into thepulmonary arteries. Instead blood returns to the lungs via passive flowfrom the systemic veins. Thus, the major physiologic consequence of thistype of palliation is that pulmonary blood flow is completely dependentupon the pressure gradient from the systemic venous bed to the atrium.The normal circulation flow through the pulmonary bed is augmented bythe increased pressure generated by the right ventricle. In a healthyadolescent, this results in an increase of about 20 to 25 mm Hg in thepressure present in the pulmonary arteries at rest, which may doublewith exercise. With the Fontan physiology, there is no sub-pulmonaryventricle and thus no augmentation of pressure as the blood enters thepulmonary arteries. At rest, the pressure gradient across the pulmonaryvascular bed is significantly less. The ability to increase thispressure gradient with exercise is extremely limited by the body'sability to tolerate increasingly elevated central venous pressures.

As a unique consequence of being entirely dependent upon the passivedrop in venous pressure to drive pulmonary blood flow, the Fontanphysiology is exquisitely sensitive to changes in pulmonary vascularresistance. Even increases that are well within the normal range forpulmonary resistance in normal physiology will have detrimental effectson the Fontan physiology. Likewise any decrease in resistance, even ifthis value is already normal, has the potential to augment pulmonaryblood flow. For this reason, the use of udenafil offers a potentialtherapy that is unique to this class of palliated congenital heartdefects. Unlike other uses for PDE-5 inhibitors, this therapy would beto lower resistance in a population without elevated pulmonaryresistances or pressures. This is a distinctly different use of thisclass of agents as compared to patients with either structurally normalhearts and pulmonary vascular disease or the very rare patient withcongenital heart disease palliated with a two ventricle repair (and thushaving a sub-pulmonary ventricle) and associated pulmonary vasculardisease.

II. Clinical Measurements Relevant to Fontan Patients

For children born with functional single ventricle congenital heartdisease, the Fontan procedure is the current standard of care. TheFontan procedure is palliative, rather than curative, and while it hasgreatly increased the survival of pediatric subjects with functionalsingle ventricle congenital heart disease, the procedure also results ina series of side effects and complications that can lead to lateattrition of patients, with complications such as arrhythmias,ventricular dysfunction, and unusual clinical syndromes ofprotein-losing enteropathy (PLE) and plastic bronchitis, as well ashepatic and kidney complications.

In certain embodiments, the disclosed invention relates to improving orpreventing the decline of specific clinically relevant measurements thatare indicative of a patient's health following a Fontan procedure. Suchmeasurements include, but are not limited to, exercise testing, vascularfunction testing, and echocardiographic assessment of ventricularperformance.

Exercise Testing

Exercise testing can include assessment of VO2 values during maximaleffort or at anaerobic threshold. VO2 max, or maximal oxygenconsumption, refers to the maximum amount of oxygen that an individualcan utilize during intense exercise. This measurement is generallyconsidered a reliable indicator of cardiovascular fitness and aerobicendurance. Theoretically, the more oxygen a person can use during highlevel exercise, the more energy that person can produce. This test isthe gold standard for cardiorespiratory fitness because muscles needoxygen for prolonged (aerobic) exercise; blood carries oxygen to themuscles and the heart must pump adequate amounts of blood to meet thedemands of aerobic exercise.

VO2 is often measured by putting a mask on a subject, and measuring thevolume and gas concentrations of inhaled and expired air. Thismeasurement is often used in both clinical settings and research and isconsidered the most accurate. Testing commonly involves eitherexercising on a treadmill or riding a bike at increasing intensity untilexhaustion, and is designed to provide readings at a maximal effort ofthe subject and/or at the subject's anaerobic threshold.

Patients that have previously undergone a Fontan procedure willgenerally see a decline in VO2 measurements over time. Treating apatient with a method according to the invention such that the patient'sVO2 measurement are either maintained at a similar level, demonstratingthat there has been no further decline in VO2 function, or improve withtherapy indicates that the treatment is clinically beneficial and mayimprove or prevent decline in cardiovascular function.

In one embodiment, the invention is directed to a method of improving ormaintaining VO2 measurements of a subject who has previously had aFontan procedure. The method comprises administering a therapeuticallyeffective amount of a PDE5 inhibitor to the patient, where the PDE5inhibitor is udenafil or a pharmaceutically acceptable salt thereof. Insome embodiments, VO2 is measured at maximal effort, while in otherembodiments, VO2 is measured at the subject's anaerobic threshold.

In some embodiments, the disclosed methods and compositions areadministered to a Fontan patient and result in no decrease, or a minimaldecrease, in exercise capacity over time. More specifically, thedisclosed methods and compositions may result in a decrease in exercisecapacity of less than about 40, less than about 35, less than about 30,less than about 35, less than about 20, less than about 15, less thanabout 10, or less than about 5% over time. The time period between afirst and second measurement used to calculate the decrease in exercisecapacity can be, for example, about 1, about 2, about 3, about 4, about5, about 6, about 7, about 8, about 9, about 10, about 11, or about 12months; about 1, about 2, about 3, about 4, about 5, about 6, about 7,about 8, about 9, about 10, about 11, about 12, about 13, about 14, orabout 15 years, or any combination thereof, e.g., 1 year, 3 months; 4years, 7 months, etc.

In some embodiments, the disclosed methods and compositions may beadministered to a Fontan patient and result in an improvement ofexercise capacity. More specifically, the disclosed methods andcompositions may result in a 1, 2, 5, 10, 15, 20, 25, 30, 35, 40, 45, or50% or more improvement in VO2 at maximal effort. Alternatively, thedisclosed methods and compositions may result in a 1, 2, 5, 10, 15, 20,25, 30, 35, 40, 45, or 50% or more improvement in VO2 at the patient'sanaerobic threshold.

Vascular Function Testing

Vascular endothelial dysfunction is an important outcome for assessingvascular health in intervention studies. It is now well established thatvascular endothelial dysfunction is positively associated withtraditional cardiovascular disease (CVD) risk factors, and independentlypredicts cardiovascular events over intervals of 1 to 6 years.

Pulse amplitude tonometry (PAT), a FDA-approved method for assessingvascular function, is increasingly being used as an alternative measureof endothelium-dependent dilation in response to reactive hyperemia andflow-mediated dilation (FMD). The PAT device records digital pulse waveamplitude (PWA) using fingertip plethysmography. PWA can be measuredcontinuously during three phases: a quiet baseline period, 5-min forearmocclusion, and reactive hyperemia following cuff release. Unlike FMD,PAT testing is not dependent upon a highly skilled technician andpost-test analysis is largely automated. Most importantly, at least onelongitudinal study has shown that PAT measures of endothelial functionpredict CVD events over a 6-year follow-up period. These significantadvantages may make PAT testing suitable for clinical practice ifprognostic significance and reliability can be verified.

Patients that have previously undergone a Fontan procedure willgenerally see a decline in vascular function over time. Treating apatient such that the patient's vascular function increases orpreventing further decline in vascular function would indicate that thetreatment is clinically beneficial and may improve patient quality oflife or prevent decline in cardiovascular function.

In one embodiment, the invention is directed to a method of improving ormaintaining vascular function of a subject who has previously had aFontan procedure. The method comprises administering a therapeuticallyeffective amount of a PDE5 inhibitor to the patient, where the PDE5inhibitor is udenafil or a pharmaceutically acceptable salt thereof. Insome embodiments, vascular function is measured using a PAT index.

In some embodiments, the disclosed methods and compositions areadministered to a Fontan patient and result in no decrease, or a minimaldecrease, in vascular function over time. Vascular function can bemeasured using any conventional known technique, including but notlimited to pulse amplitude tonometry measurements, the natural log ofreactive hyperemia index, Reactive Hyperemia Index, Framingham RHI, areaunder the curve to max-occlusion/control, average up tomax-occlusion/control, and other known EndoPAT indices. In someembodiments, vascular function is measured using a PAT index. Morespecifically, the disclosed methods and compositions may result in adecrease in vascular function of less than about 40, less than about 35,less than about 30, less than about 35, less than about 20, less thanabout 15, less than about 10, or less than about 5% over time. The timeperiod between a first and second measurement used to calculate thedecrease in vascular function can be, for example, about 1, about 2,about 3, about 4, about 5, about 6, about 7, about 8, about 9, about 10,about 11, or about 12 months; about 1, about 2, about 3, about 4, about5, about 6, about 7, about 8, about 9, about 10, about 11, about 12,about 13, about 14, or about 15 years, or any combination thereof, e.g.,1 year, 3 months; 4 years, 7 months, etc.

In some embodiments, the disclosed methods and compositions may beadministered to a Fontan patient and result in an improvement ofvascular function. Vascular function can be measured using anyconventional known technique, including but not limited to pulseamplitude tonometry measurements, the natural log of reactive hyperemiaindex, Reactive Hyperemia Index, Framingham RHI, area under the curve tomax-occlusion/control, average up to max-occlusion/control, and otherknown EndoPAT indices. In some embodiments, vascular function ismeasured using a PAT index. More specifically, the disclosed methods andcompositions may result in about a 1, about 2, about 5, about 10, about15, about 20, about 25, about 30, about 35, about 40, about 45, or about50% or more improvement in one or more measurements of vascularfunction, including but not limited to pulse amplitude tonometrymeasurement, the natural log of reactive hyperemia index, ReactiveHyperemia Index, Framingham RHI, area under the curve tomax-occlusion/control, average up to max-occlusion/control, and otherknown EndoPAT indices.

Echocardiographic Assessment of Ventricular Performance

Ventricular performance and cardiac contractility are importantmeasurements that can reveal impairment of cardiovascular health beforeovert heart failure is present. Ventricular performance can be assessedusing echocardiographic methods and quantified via a myocardialperformance index or MPI. MPI is an index that combines systolic anddiastolic function. Specifically, MPI is defined as the sum ofisovolumic contraction time and isovolumic relaxation time divided bythe ejection time.

Various versions of MPI are known in the art, and each version of MPImay be used to assess ventricular performance. For instance, MPI indicesmay include but are not limited to blood pool MPI, tissue doppler MPI,average isovolumetric contraction, and average isovolumetric relaxation.

Patients that have previously undergone a Fontan procedure willgenerally see a decline in ventricular performance over time. Treating apatient such that the patient's ventricular performance is maintained,exhibits minimal decrease over time, or increases indicates that thetreatment is clinically beneficial and may improve patient quality oflife or prevent decline in cardiovascular function.

In one embodiment, the invention is directed to a method of maintaining,producing a minimal decrease in, or increasing ventricular performanceof a subject who has previously had a Fontan procedure. The methodcomprises administering a therapeutically effective amount of a PDE5inhibitor to the patient, where the PDE5 inhibitor is udenafil or apharmaceutically acceptable salt thereof. In some embodiments,ventricular performance is measured using a myocardial performance index(MPI). In some embodiments, the MPI may be a blood pool MPI, while inother embodiments the MPI may be a tissue doppler MPI.

In some embodiments, the disclosed methods and compositions may beadministered to a Fontan patient and result in minimal or no decrease inventricular performance over time. Ventricular performance can bemeasured using any conventional known technique, including but notlimited to myocardial performance index (MPI), blood pool MPI, tissuedoppler MPI, average isovolumetric contraction and relaxation, and otherknown ventricular performance indices. More specifically, the disclosedmethods and compositions may result in a decrease in ventricularperformance of less than about 40, less than about 35, less than about30, less than about 35, less than about 20, less than about 15, lessthan about 10, or less than about 5% over time. The time period betweena first and second measurement used to calculate the decrease inventricular performance can be, for example, about 1, about 2, about 3,about 4, about 5, about 6, about 7, about 8, about 9, about 10, about11, or about 12 months; about 1, about 2, about 3, about 4, about 5,about 6, about 7, about 8, about 9, about 10, about 11, about 12, about13, about 14, or about 15 years, or any combination thereof, e.g., 1year, 3 months; 4 years, 7 months, etc.

In some embodiments, the disclosed methods and compositions may beadministered to a Fontan patient and result in an improvement ofventricular performance over time. Ventricular performance can bemeasured using any conventional known technique, including but notlimited to myocardial performance index (MPI), blood pool MPI, tissuedoppler MPI, average isovolumetric contraction and relaxation, and otherknown ventricular performance indices. For example, the disclosedmethods and compositions may result in about a 1, about 2, about 5,about 10, about 15, about 20, about 25, about 30, about 35, about 40,about 45, or about 50% or more improvement in ventricular performance,as measured by any known technique, including but not limited tomyocardial performance index (MPI), blood pool MPI, tissue doppler MPI,average isovolumetric contraction and relaxation, and other knownventricular performance indices.

III. Methods According to the Invention

In one embodiment, the invention is directed to methods of treating,preventing, or minimizing conditions, symptoms, or side effectsassociated with a subject who has previously had a Fontan procedure. Themethod comprises administering a therapeutically effective amount of aPDE5 inhibitor to the patient, where the PDE5 inhibitor is udenafil or apharmaceutically acceptable salt thereof.

In the Fontan circulation, pulmonary blood flow is passive, driven bythe pressure difference between the systemic venous circulation and theventricular end-diastolic pressure. A medication capable of allowing formore efficient transit of blood through the pulmonary vascular bed canallow for improvement in cardiac preload, and therefore improve cardiacoutput.

PDE5 inhibitors are a class of medications that reduce pulmonaryvascular resistance and improve ventricular performance in patients withpulmonary hypertension and myocardial dysfunction.

Some studies have evaluated the single-use or longer-term use ofsildenafil in children and young adults who have had the Fontanprocedure. However, sildenafil has a short half-life, and is typicallyadministered three to four times per day. Such an administrationschedule is not convenient and is likely to reduce patient compliance.In addition, the administration of a short half-life drug results ingreater fluctuations of therapeutic levels of drug, increasing the riskthat the blood level of the PDE5 inhibitor will drop below thetherapeutically effective level for parts of the day. The presentinventors hypothesize that administration of a PDE5 inhibitor having alonger half-life to patients who have had the Fontan procedure willprevent or ameliorate the decline in aerobic exercise performance inpatients following the Fontan procedure.

Patient compliance is critical for optimal therapeutic efficacy,particularly for a drug that is to be taken daily for an extended periodof time, such as for several years or more. This is particularly truefor Fontan patients. In particular, individuals that had the Fontanprocedure most often die from heart failure, stroke (thrombosis), orsome unexplained sudden death. Of note is the fact that the risk ofdeath from heart failure is quite low within 10 years of the Fontanprocedure but increases with time after 10 years post-Fontan.http://bendantzer.wordpress.com/2013/03/13/fontan-circulation-success-or-failure/.

Not surprisingly, as time passes from the date of the Fontan procedure,the risk of death or need from a heart transplant increases. This couldbe from some sudden death or heart failure, but it could also be from agradual decline in heart function. As the years tick by after the Fontanprocedure, heart function gets worse, which is reflected in the declinein the ability to do aerobic exercise. For example, for patients thathad the Fontan early in life, they may have exercise capacity that ishighly reduced (44%) compared to normal patients and this capacity to doexercise tends to decline in a linear fashion each year (declines 2.6%each year). At thirty years of age, patients with Fontan circulationhave much reduced exercise capacity (55% less than normal) and thenumber of health problems and hospitalization rates increasedramatically. This is probably not surprising since, again, oneventricle is doing the work of two. Thus, methods according to theinvention which can diminish or significantly decrease decline in heartfunction over time, are highly desirable for Fontan patients. Key to thesuccess of such methods is patient compliance with a preferred dosingschedule.

Patient compliance, or lack thereof, to a prescribed dosing schedule isknown to be a critical factor in the success of any therapy. Inparticular, quality healthcare outcomes depend upon patients' adherenceto recommended treatment regimens. Patient nonadherence can be apervasive threat to health and wellbeing and carry an appreciableeconomic burden as well. In some disease conditions, more than 40% ofpatients sustain significant risks by misunderstanding, forgetting, orignoring healthcare advice. Moreover, when preventive or treatmentregimens are very complex and/or require lifestyle changes and themodification of existing habits, nonadherence can be as high as 70%.Martin et al., Ther. Clin. Risk Manag., 1(3): 189-199 (2005) (“Asignificant barrier to effective medical treatment, however, is thepatient's failure to follow the recommendations of his or her physicianor other healthcare provider.”). Thus, a therapy that can produce thedesired results (e.g., improved cardiac output, decreased pulmonaryvascular resistance, improved exercise capacity, improved myocardialperformance, preventing or ameliorating the decline in aerobic exerciseperformance), with a preferred once or twice a day dosage, as comparedto multiple daily dosages—e.g., 3 to 6× daily—required to be taken atleast 4 to 6 hours apart, such as with sildenafil, is highly desirable.Such a more simplistic dosing regimen is likely to lead to a significantincrease in patient compliance, and concomitant improved therapeuticresults.

In one embodiment, the invention is directed to a method of improvingcardiac output in a patient who has had the Fontan procedure, the methodcomprising administering a therapeutically effective amount of the PDE5inhibitor udenafil, or a pharmaceutically acceptable salt thereof, tothe patient. For example, the method of the invention can result in animprovement in cardiac output, as compared to a subject who is notadministered udenafil, of about 5%, about 8%, about 10%, about 15%,about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, orabout 50%.

In another embodiment, the invention is directed to a method ofdecreasing pulmonary vascular resistance in a patient who has had theFontan procedure, the method comprising administering a therapeuticallyeffective amount of the PDE5 inhibitor udenafil, or a pharmaceuticallyacceptable salt thereof, to the patient. For example, the method of theinvention can result in an decreased pulmonary vascular resistance, ascompared to a subject who is not administered udenafil, of about 5%,about 8%, about 10%, about 15%, about 20%, about 25%, about 30%, about35%, about 40%, about 45%, or about 50%.

In yet another embodiment, the invention is directed to a method ofimproving exercise capacity in a patient who has had the Fontanprocedure, the method comprising administering a therapeuticallyeffective amount of the PDE5 inhibitor udenafil, or a pharmaceuticallyacceptable salt thereof, to the patient. For example, the method of theinvention can result in an increase in exercise capacity measured bymaximal VO2, as compared to a subject who is not administered udenafil,of about 5%, about 8%, about 10%, about 15%, about 20%, about 25%, about30%, about 35%, about 40%, about 45%, or about 50%.

In one embodiment, the invention is directed to a method of improvingmyocardial performance in a patient who has had the Fontan procedure,the method comprising administering a therapeutically effective amountof a PDE5 inhibitor to the patient. For example, the method of theinvention can result in an improvement in myocardial performance, ascompared to a subject who is not administered udenafil, of about 5%,about 8%, about 10%, about 15%, about 20%, about 25%, about 30%, about35%, about 40%, about 45%, or about 50%.

In one embodiment, the invention is directed to a method of preventingor ameliorating the decline in aerobic exercise performance in a patientwho has had the Fontan procedure, the method comprising administering atherapeutically effective amount of the PDE5 inhibitor udenafil, or apharmaceutically acceptable salt thereof, to the patient. For example,the method of the invention can result in an amelioration of the declinein aerobic exercise performance measured by maximal VO2, as compared toa subject who is not administered udenafil, of about 5%, about 8%, about10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%,about 45%, or about 50%.

In yet another embodiment, the invention is directed to improved methodsfor treating a patient who has had a Fontan procedure, wherein themethods show an improvement in patient compliance with a dosing scheduleof udenafil or a pharmaceutically acceptable salt thereof, as comparedto patients prescribed a non-udenafil drug.

Udenafil has a half-life of 7.3-12.1 hours, and is believed to possiblyhave a much better safety profile as compared to sildenafil ortadalafil. Udenafil has unique properties, with a T_(max) of 1.0-1.5 hand a T_(1/2) of 11-13 h (a relatively rapid onset and a long durationof action). Therefore, both on-demand and once-daily use of udenafilhave been reported. Udenafil's efficacy and tolerability have beenevaluated in several studies, and recent and continuing studies havedemonstrated udenafil's promise in both dosing regimens. Presently,tadalafil is the only FDA-approved drug for daily dosing, but udenafilcan be used as a once-daily dose for erectile dysfunction patients whocannot tolerate tadalafil due to phosphodiesterase subtype selectivity.Gu Kang et al., Ther. Adv. Urol., 5(2): 101-110 (2013). Once-dailydosing of udenafil was evaluated for the treatment of erectiledysfunction (ED), and the results showed that udenafil significantlyimproved erectile function among ED patients when administered in dosesof 50 mg or 75 mg once daily for 12 wk. Zhao et al., Eur. J. of Urology,60: 380-387 (2011). While these reports suggest that udenafil may beuseful as a once a day therapy for various conditions, other reportsshow that PDE5 inhibitors show varying efficacy in treating symptomsassociated with the Fontan operation. Sabri et al., Pediatr. Cardiol.,35(4):699-704 (2014).

Thus, it was surprising that the present invention, directed to methodsof treating, minimizing, and/or preventing symptoms associated with theFontan operation comprising administering udenafil or a pharmaceuticallyacceptable salt thereof, shows desirable results, preferably with a onceor twice a day dosage. “Desirable results” include, but are not limitedto, improved cardiac output, decreased pulmonary vascular resistance,improved exercise capacity, improved myocardial performance, preventingor ameliorating the decline in aerobic exercise performance, and/or animprovement in patient compliance.

In one embodiment of the invention, once a day administration of atherapeutically effective dosage of uldenafil, or a pharmaceuticallyacceptable salt thereof, results in therapeutic levels of uldenafil,present in the patient's blood stream, for up to about 8 hours. In otherembodiments of the invention, once a day administration of atherapeutically effective dosage of uldenafil, or a pharmaceuticallyacceptable salt thereof, results in therapeutic levels of uldenafil,present in the patient's blood stream, for up to about 10, about 11,about 12, about 13, about 14, about 15, about 16, about 17, about 18,about 19, about 20, about 21, about 22, about 23, or about 24 hours.

In one embodiment of the invention, twice a day administration of atherapeutically effective dosage of udenafil, or a pharmaceuticallyacceptable salt thereof, results in therapeutic levels of udenafil forat least about 16 hours in a 24 hour dosing period. In otherembodiments, twice a day administration of a therapeutically effectivedosage of udenafil, or a pharmaceutically acceptable salt thereof,results in therapeutic levels of udenafil for at least about 9 hours,about 10 hours, about 11 hours, about 12 hours, about 13 hours, about 14hours, about 15 hours, about 16 hours, about 17 hours, about 18 hours,about 19 hours, about 20 hours, about 21 hours, about 22 hours, about 23hours, or about 24 hours, in a 24 hour dosing period.

In another embodiment, it was surprising that that the methods of theinvention show improved results as compared to prior art treatmentsusing a non-udenafil PDE5 inhibitor, such as sildenafil or tadalafil. Inyet another embodiment, it was surprising that the methods of theinvention show fewer side effects, and/or less severe side effects, ascompared to prior art treatments using a non-udenafil PDE5 inhibitor,such as sildenafil or tadalafil.

In one embodiment, it is surprising that the administration of twice aday udenafil or a pharmaceutically acceptable salt thereof results infewer side effects than the administration of once a day udenafil or apharmaceutically acceptable salt thereof. In another embodiment, it issurprising that twice a day administration of udenafil or apharmaceutically acceptable salt thereof can achieve therapeuticallyeffective levels of udenafil at a lower total daily dosage than a once aday administration.

In one embodiment, the patient who has had the Fontan procedure is ahuman patient. In one embodiment, the patient is an adult human patientover about 18 years of age. In another embodiment, the patient is apediatric patient of about 2 to about 18 years of age. In anotherembodiment, the patient is a pediatric patient of about 12 to about 18years of age, or from about 12 to about 16 years of age.

IV. Pediatric Patients

Treatment of pediatric patients presents particular challenges, aspediatric physiology is not just a miniature version of an adult.Physical size is just one of the many differences. Children's bodysurface area, organ and system maturity and function, as well ascognitive and emotional development can result in differences inresponse to illness, diagnosis, treatment, and medications. Evenillnesses that are seen in adults can act differently in childrenbecause of their unique anatomy and physiology. Moreover, pediatricpatients process drugs differently than adults, and therefore theeffects as well as the dosages of drugs may vary widely from thoseobserved with adults. Since children differ from adults in many waysbeyond size, simply adjusting the dose of a drug for a smaller sizeperson will not necessarily produce the same response and can lead toadverse drug reactions. Thus, the effectiveness of a drug used intreating an adult condition does not with certainty predict success oftreating a pediatric patient with the same drug.

Thus, the invention is also directed to the surprising discovery thatpediatric Fontan patients can be successfully treated with the methodsof the invention. The methods comprise administering a therapeuticallyeffective amount of a PDE5 inhibitor to the pediatric patient, where thePDE5 inhibitor is udenafil or a pharmaceutically acceptable saltthereof.

The structure of udenafil is shown below:

V. Doses and Dosage Forms

In one embodiment, the udenafil or a pharmaceutically acceptable saltthereof is administered at total daily dosage amounts of about 0.01 toabout 150 mg/kg. In another embodiment, the udenafil or apharmaceutically acceptable salt thereof is administered at total dailydoses of about 0.01 mg/kg up to about 30 mg/kg. In another embodiment,the udenafil or a pharmaceutically acceptable salt thereof isadministered at total daily doses of about 5 mg, about 10 mg, about 15mg, about 20 mg, about 25 mg, about 27.5 mg, about 30 mg, about 32.5,about 35 mg, about 37.5 mg, about 40 mg, about 42.5 mg, about 45 mg,about 47.5 mg, about 50 mg, about 55 mg, about 60 mg, about 65 mg, about70 mg, about 75 mg, about 80 mg, about 85 mg, about 87.5 mg, about 90mg, about 95 mg, about 100 mg, about 125 mg, about 150 mg, about 175 mg,about 200 mg, about 225 mg, about 250 mg, or about 275 mg. In oneembodiment, the udenafil or a pharmaceutically acceptable salt thereofis administered in total daily doses of about 25 mg, about 37.5 mg,about 50 mg, about 75 mg, about 87.5 mg, 125 mg, about 175 mg, about 200mg, about 225 mg, about 250 mg, about 275 mg, about 300 mg, about 325mg, about 350 mg, about 375 mg, about 400 mg, about 425 mg, about 450mg, about 475 mg, about 500 mg, about 525 mg, about 550 mg, about 575mg, about 600 mg, about 625 mg, about 650 mg, about 675 mg, or about 700mg. In another particular embodiment, udenafil or a pharmaceuticallyacceptable salt thereof is administered at a total daily dose of about37.5 mg, about 75 mg, about 87.5 mg, 125 mg, or about 175 mg.

In one embodiment, the udenafil or a pharmaceutically acceptable saltthereof is administered once a day.

In another embodiment, the udenafil or a pharmaceutically acceptablesalt thereof is administered twice a day. In one embodiment, theudenafil or a pharmaceutically acceptable salt thereof is administeredtwice a day such that therapeutically effective blood levels aremaintained for at least about 18, about 19, about 20, about 21, about22, about 23 or about 24 hours of a 24 hour dosing period. In someembodiments, the total daily dosage amount of udenafil or apharmaceutically acceptable salt administered twice a day is less thanthe total daily dosage amount of udenafil or a pharmaceuticallyacceptable salt thereof administered once a day. In some embodiments,the total daily dosage amount of udenafil or a pharmaceuticallyacceptable salt thereof administered twice a day, maintainstherapeutically effective blood levels for the same number of hours in a24 hour period as a higher dosage of udenafil or a pharmaceuticallyacceptable salt thereof when administered once a day. In otherembodiments, the total daily dosage amount of udenafil or apharmaceutically acceptable salt thereof administered twice a day,maintains therapeutically effective blood levels for a higher number ofhours in a 24 hour period as the same dosage of udenafil or apharmaceutically acceptable salt thereof when administered once a day.

In some embodiments, the udenafil or a pharmaceutically acceptable saltthereof administered twice a day produces a greater reduction in theconditions, symptoms, or side effects associated with a subject who haspreviously had a Fontan procedure, when compared to udenafil or apharmaceutically acceptable salt thereof administered once a day.

In some embodiments, the pharmaceutically acceptable salt of udenafil isan acid addition salt. In one embodiment, the acid addition salt ofudenafil is an inorganic acid addition salt such as, hydrochloric,hydrobromic, sulfuric, or phosphoric acid addition salt. In anotherembodiment, the acid addition salt is an organic acid addition salt suchas citrate, tartarate, acetate, lactate, maleate, fumarate, gluconate,methanesulfonate (mesylate), glycolate, succinate, p-toluenesulfonate(tosylate), galacturonate, embonate, glutamate, aspartate, oxalate,benzensulfonate, camphorsulfonate, cinnamate, adipate, or cyclamate. Ina particular embodiment, the pharmaceutically acceptable salt ofudenafil is an oxalate, benzensulfonate, camphorsulfonate, cinnamate,adipate, or cyclamate salt.

In one embodiment the udenafil or a pharmaceutically acceptable saltthereof is administered as a pharmaceutical composition. In oneembodiment, the pharmaceutical composition comprising udenafil or apharmaceutically acceptable salt thereof can be formulated in a widevariety of oral or parenteral dosage forms on clinical application. Eachof the dosage forms can contain various disintegrating agents,surfactants, fillers, thickeners, binders, diluents such as wettingagents or other pharmaceutically acceptable excipients.

The udenafil composition can be administered using any pharmaceuticallyacceptable method, such as intranasal, buccal, sublingual, oral, rectal,ocular, parenteral (intravenously, intradermally, intramuscularly,subcutaneously, intracisternally, intraperitoneally), pulmonary,intravaginal, locally administered, topically administered, topicallyadministered after scarification, mucosally administered, via anaerosol, or via a buccal or nasal spray formulation.

Further, the udenafil composition can be formulated into anypharmaceutically acceptable dosage form, such as a solid dosage form,tablet, pill, lozenge, capsule, liquid dispersion, gel, aerosol,pulmonary aerosol, nasal aerosol, ointment, cream, semi-solid dosageform, and a suspension. Further, the composition may be a controlledrelease formulation, sustained release formulation, immediate releaseformulation, or any combination thereof. Further, the composition may bea transdermal delivery system.

In another embodiment, the pharmaceutical composition comprisingudenafil or a pharmaceutically acceptable salt thereof can be formulatedin a solid dosage form for oral administration, and the solid dosageform can be powders, granules, capsules, tablets or pills. In yetanother embodiment, the solid dosage form can include one or moreexcipients such as calcium carbonate, starch, sucrose, lactose,microcrystalline cellulose or gelatin. In addition, the solid dosageform can include, in addition to the excipients, a lubricant such astalc or magnesium stearate. In some embodiments, the oral dosage formcan be immediate release, or a modified release form. Modified releasedosage forms include controlled or extended release, enteric release,and the like. The excipients used in the modified release dosage formsare commonly known to a person of ordinary skill in the art.

In a further embodiment, the pharmaceutical composition comprisingudenafil or a pharmaceutically acceptable salt thereof can be formulatedas a sublingual or buccal dosage form. Such dosage forms comprisesublingual tablets or solution compositions that are administered underthe tongue and buccal tablets that are placed between the cheek and gum.

In yet a further embodiment, the pharmaceutical composition comprisingudenafil or a pharmaceutically acceptable salt thereof can be formulatedas a nasal dosage form. Such dosage forms of the present inventioncomprise solution, suspension, and gel compositions for nasal delivery.

In one embodiment, the pharmaceutical composition can be formulated in aliquid dosage form for oral administration, such as suspensions,emulsions or syrups. In other embodiments, the liquid dosage form caninclude, in addition to commonly used simple diluents such as water andliquid paraffin, various excipients such as humectants, sweeteners,aromatics or preservatives. In particular embodiments, the compositioncomprising udenafil or a pharmaceutically acceptable salt thereof can beformulated to be suitable for administration to a pediatric patient.

In one embodiment, the pharmaceutical composition can be formulated in adosage form for parenteral administration, such as sterile aqueoussolutions, suspensions, emulsions, non-aqueous solutions orsuppositories. In other embodiments, the non-aqueous solutions orsuspensions can include propyleneglycol, polyethyleneglycol, vegetableoils such as olive oil or injectable esters such as ethyl oleate. As abase for suppositories, witepsol, macrogol, tween 61, cacao oil, laurinoil or glycerinated gelatin can be used.

The dosage of the pharmaceutical composition can vary depending on thepatient's weight, age, gender, administration time and mode, excretionrate, and the severity of disease.

VI. Adverse Events

Adverse events are an important consideration, particularly whentreating a susceptible population such as pediatric patients with Fontanphysiology. PDE-5 inhibitors may produce adverse events including eyeand/or hearing issues. Therefore, developing methods in which PDE-5inhibitors such as udenafil or a pharmaceutically acceptable saltthereof can safely be administered to pediatric patients is one aspectof the invention.

In some embodiments, a pediatric patient with Fontan physiology may beadministered a PDE-5 inhibitor to treat, minimize, and/or prevent thedeleterious effects of Fontan physiology. In some embodiments,administering the PDE-5 inhibitor, specifically udenafil or apharmaceutically acceptable salt thereof, results in minimal if anyserious adverse events. In other embodiments, administering the PDE-5inhibitor, specifically udenafil or a pharmaceutically acceptable saltthereof, results in minimal if any unexpected adverse events.

In some embodiments, a pediatric patient with Fontan physiology beingadministered udenafil or a pharmaceutically acceptable salt thereof mayexperience only mild adverse events related to the medication, and inother embodiments, the patient may experience only moderate adverseevents related to the medication. In some embodiments, a pediatricpatient with Fontan physiology being administered udenafil or apharmaceutically acceptable salt thereof may experience fewer, lessfrequent, or less severe adverse events compared to a Fontan patientreceiving another PDE-5 inhibitor.

VII. Pharmacokinetic Parameters

Pharmacokinetics refers to the absorption, distribution, metabolism, andexcretion of a drug once it has been administered to a subject. Thekinetics of a drug have an impact on the drug's efficacy and toxicity. Agiven drug's kinetic profile can depend not only on the compound itself,but also on the size of the dose and the dosing regimen as well as howthe drug is formulated and administered. Pharmacokinetic parameters thatmay be useful in determining clinical utility include but are notlimited to plasma concentration, plasma concentration over time, maximumplasma concentration (C_(max)), time to reach maximum concentration(T_(max)), area under concentration time curve within the dosinginterval (AUC_(τ)), daily area under concentration time curve at steadystate (AUC₀₋₂₄); CL/F, apparent clearance; V/F, apparent volume ofdistribution; ke, elimination rate constant; T½, terminal half-life.

In some embodiments, the disclosed invention is directed to methods ofadministering udenafil or a pharmaceutically acceptable salt thereof toa patient with Fontan physiology, wherein the administration results ina unique pharmacokinetic profile. For instance, in some embodiments thedisclosed methods can produce plasma concentrations of udenafil rangingfrom about 10 to about 700 ng/ml, about 50 to about 650 ng/ml, about 100to about 600 ng/ml, about 150 to about 550 ng/ml, or about 200 to about500 ng/ml. In other words, dosing regimens of the disclosed methods mayresult in sustained plasma concentrations of udenafil above 25, 50, 75,100, 125, 150, 175, 200, 225, 250, 275, 300, 325, 350, 375, 400, 425,450, 475, 500, 525, 550, 575, 600, 625, 650, 675, or 700 ng/ml. In someembodiments, the plasma concentration is maintained above about 140ng/ml.

In some embodiments, the disclosed methods include a characteristicpharmacokinetic profile in which the C_(max) is about 25, about 50,about 75, about 100, about 125, about 150, about 175, about 200, about225, about 250, about 275, about 300, about 325, about 350, about 375,about 400, about 425, about 450, about 475, about 500, about 525, about550, about 575, about 600, about 625, about 650, about 675, or about 700ng/ml. In some embodiments, the C_(m), is about 506.

In some embodiments, the disclosed methods include a characteristicpharmacokinetic profile in which the T_(m), is about 0.1, 0.2, 0.3, 0.4,0.5, 0.6, 0.7, 0.8, 0.9, 1.0, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8,1.9, 2.0, 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, 2.9, or 3.0 hours(hr). In some embodiments, the T_(max) is about 1.3 hr.

In some embodiments, the disclosed methods include a characteristicpharmacokinetic profile in which the area under the curve (AUC) isunique to a therapeutically effective dose of udenafil in a Fontan'spatient. For instance AUC_(τ) is between 750 and 4500 ng·hr/ml, 800-4000ng·hr/ml, or 850-3500 ng·hr/ml. More specifically AUC_(τ) is about 750,about 800, about 850, about 900, about 950, about 1000, about 1050,about 1100, about 1150, about 1200, about 1250, about 1300, about 1400,about 1500, about 1600, about 1700, about 1800, about 1900, about 2000,about 2100, about 2200, about 2300, about 2400, about 2500, about 2600,about 2700, about 2800, about 2900, about 3000, about 3100, about 3200,about 3300, about 3400, about 3500, about 3600, about 3700, about 3800,about 3900, about 4000, about 4100, about 4200, about 4300, about 4400,or about 4500 ng·hr/ml. In some embodiments, the AUC_(τ) is about 3350.

In some embodiments, AUC₀₋₂₄ is between 750 and 8500 ng·hr/ml, 800-8000ng·hr/ml, or 850-7500 ng·hr/ml. More specifically AUC₀₋₂₄ is about 750,about 800, about 850, about 900, about 950, about 1000, about 1050,about 1100, about 1150, about 1200, about 1250, about 1300, about 1400,about 1500, about 1600, about 1700, about 1800, about 1900, about 2000,about 2100, about 2200, about 2300, about 2400, about 2500, about 2600,about 2700, about 2800, about 2900, about 3000, about 3100, about 3200,about 3300, about 3400, about 3500, about 3600, about 3700, about 3800,about 3900, about 4000, about 4100, about 4200, about 4300, about 4400,about 4500, about 4600, about 4700, about 4800, about 4900, about 5000,about 5100, about 5200, about 5300, about 5400, about 5500, about 5600,about 5700, about 5800, about 5900, about 6000, about 6100, about 6200,about 6300, about 6400, about 6500, about 6600, about 6700, about 6800,about 6900, about 7000, about 7100, about 7200, about 7300, about 7400,about 7500, about 7600, about 7700, about 7800, about 7900, about 8000,about 8100, about 8200, about 8300, about 8400, or about 8500 ng·hr/ml.In some embodiments, the AUC₀₋₂₄ is about 6700.

In some embodiments, the pharmacodynamics results of administeringudenafil to a patient with Fontan's physiology can be attributed to thecharacteristic pharmacokinetic profile of the drug administration orregimen.

VIII. Definitions

As used herein, the term “about” will be understood by persons ofordinary skill in the art and will vary to some extent depending uponthe context in which it is used. If there are uses of the term which arenot clear to persons of ordinary skill in the art given the context inwhich it is used, “about” will mean up to plus or minus 10% of theparticular term.

“A treatment” is intended to target the disease state and combat it,i.e., ameliorate or prevent the disease state. The particular treatmentthus will depend on the disease state to be targeted and the current orfuture state of medicinal therapies and therapeutic approaches. Atreatment may have associated toxicities.

The terms “administration of or “administering” an active agent shouldbe understood to mean providing an active agent of the invention to thesubject in need of treatment in a form that can be introduced into thatindividual's body in a therapeutically useful form and therapeuticallyeffective amount.

The term “therapeutically effective amount” refers to a sufficientquantity of the active agents of the present invention, in a suitablecomposition, and in a suitable dosage form to treat or prevent thesymptoms, progression, or onset of the complications seen in patientswho have had the Fontan procedure. The therapeutically effective amountwill vary depending on the state of the patient's condition or itsseverity, and the age, weight, etc., of the subject to be treated. Atherapeutically effective amount can vary, depending on any of a numberof factors, including, e.g., the route of administration, the conditionof the subject, as well as other factors understood by those in the art.

The term “treatment” or “treating” generally refers to an interventionin an attempt to alter the natural course of the subject being treated,and can be performed either for prophylaxis or during the course ofclinical pathology. Desirable effects include, but are not limited to,preventing occurrence or recurrence of disease, alleviating symptoms,suppressing, diminishing or inhibiting any direct or indirectpathological consequences of the disease, ameliorating or palliating thedisease state, and causing remission or improved prognosis.

The terms “individual,” “host.” “subject,” and “patient” are usedinterchangeably herein.

As used herein, “improving cardiac output” means an increase in thevolume of blood pumped by the heart. The cardiac output is commonlymeasured as a function of the oxygen consumption.

As used herein, the term “exercise capacity” refers to the maximumamount of physical exertion that a patient can sustain. Exercisecapacity can be measured by a number of different clinical methods,including by interview or by direct measurement. The present methodsinclude different methods of measuring exercise capacity, including butnot limited to, riding a cycle ergometer or walking on a treadmill.Thus, the term “improving exercise capacity” means increasing theability of the patient to perform any level of physical exertion orexercise.

As used herein, the term “decreasing pulmonary vascular resistance”refers to decreasing or reducing the resistance offered by lungvasculature to blood flow.

As used herein, “improving myocardial performance” refers to an increaseor decrease, as the case can be, in specific heart functionmeasurements, including but not limited to, specificelectrocardiographic readings, echocardiographic readings, cardiacoutput measures, heart rate, systolic or diastolic pressure, forcedvital capacity, oxygen saturation, and respiratory rate.

As used herein, “aerobic exercise performance” refers to the ability ofa patient to perform a specified aerobic exercise.

As used herein, “pediatric” refers to a population of subjects rangingbetween a newborn and about 18 years of age. A pediatric subject caninclude a subject that begins a course of treatment with the disclosedcompositions or according to the disclosed methods prior to turningabout 18 years of age, even if the subject continues treatment beyond 18years of age. More specifically, within the population of “pediatric”subjects, neonates may be defined as 1 week to 1 month in age, infantsmay be 1 to less than 2 years of age, toddlers may be 2 to less than 6years of age, and school age may refer to subjects 6-18 years of age.

The following examples are given to illustrate the present invention. Itshould be understood, however, that the invention is not to be limitedto the specific conditions or details described in these examples. Allprinted publications referenced herein are specifically incorporated byreference.

EXAMPLES Example 1—Phase I/II Pharmacokinetic and Pharmacodynamic Study

A Phase I/II dose escalation trial of Udenafil in adolescents withsingle ventricle physiology after Fontan palliation was conducted.

The trial was conducted over a 5 month period, with an additional 3month follow-up period for adverse events (AE). The 36 subjects enrolledin the trial were comprised of 6 cohorts, as described in Table 1.

TABLE 1 Dose escalation design Cohort Cohort Cohort Cohort Cohort Cohort1 2 3 4 5 6 Dose 37.5 mg 37.5 mg 87.5 mg 87.5 mg 125 mg Control dailytwice daily twice daily (no drug) daily daily N 6 6 6 6 6 6

The goals for this trial were to assess the safety of udenafil atmultiple dose levels over a five-day period, the pharmacokinetic profileof udenafil in adolescents with Fontan physiology, and the short-termeffect of udenafil on pharmacodynamic measures of exercise capacity,ventricular performance, and vascular function.

Multiple doses of udenafil or a pharmaceutically acceptable salt thereofwere administered to male and female Fontan patients who are 14-18 yearsof age.

Inclusion Criteria for the trial were:

-   -   Males and females with Fontan physiology who are 14-18 years of        age.    -   Willingness to return to center to complete blood draws and        exercise tests as described in the study protocol.    -   Patients must agree to abstain from alcohol, caffeinated        beverages, and grapefruit juice for the duration of the trial.    -   Informed assent from subject and informed consent from        parent/legal guardian as appropriate.

Exclusion Criteria for the study include:

-   -   Non-cardiac medical, psychiatric, and/or social disorder that        would prevent successful completion of planned study testing or        would invalidate its results.    -   Height <132 cm (minimum height requirement for exercise stress        testing).    -   Known Fontan baffle obstruction, branch pulmonary artery        stenosis, or pulmonary vein stenosis resulting in a mean        gradient of >4 mmHg between the regions proximal and distal to        the obstruction.    -   Single lung physiology.    -   Severe ventricular dysfunction or valvular regurgitation        (systemic atrioventricular or semilunar valve) determined from        review of the echocardiogram performed in closest proximity to        study enrollment.    -   Significant renal (serum creatinine >2.0), hepatic (serum AST        and/or ALT>3 times upper limit of normal), gastrointestinal or        biliary disorders that could impair absorption, metabolism or        excretion of orally administered medications, based on        laboratory assessment at the time of screening visit.    -   Hospitalization for acute decompensated heart failure within the        12 months preceding study screening.    -   A diagnosis of active protein-losing enteropathy or plastic        bronchitis.    -   Active evaluation or listing for heart transplant.    -   History of use of a PDE5 inhibitor within three months of study        screening.    -   Concurrent illness that, in the opinion of the investigator,        precludes participation.    -   Current therapy with alpha-blockers or nitrates.    -   Pregnancy at the time of enrollment.    -   Latex allergy.

Table 2 presents baseline characteristics of 36 enrolled subjects—inaggregate (2nd column) and for each of the 6 individual cohorts. Medianage of enrolled subjects is 16 years (with the range from 14 to 18years), 58% were male, 78% were white and 6% were Hispanic. There wereno significant differences in baseline characteristics among the cohorts(right column).

TABLE 2 Baseline Characteristics for Enrolled Subjects 37.5 mg 37.5 mg87.5 mg 87.5 mg 125 mg Exercise Overall daily twice daily daily twicedaily daily testing only Characteristic (N = 36) (N = 6) (N = 6) (N = 6)(N = 6) (N = 6) (N = 6) P-value * Age, year 15.8 ± 1.3 15.5 ± 1.0 16.2 ±0.8 15.0 ± 0.9 15.5 ± 1.8 16.5 ± 1.5 16.2 ± 1.2 0.319 Median 16 (15, 17)16 (15, 16)  16 (16, 17)  15 (14, 16) 15 (14, 17) 17 (16, 18) 16 (15,17) 0.309 (Interquartile Range) Range, Min-Max 14-18 14-17 15-17 14-1614-18 14-18 15-18 Male 21 (58.3%) 4 (66.7%) 3 (50.0%) 3 (50.0%) 3(50.0%) 4 (66.7%) 4 (66.7%) 1.000 Hispanic or 2 (5.7%) 1 (16.7%) 1(16.7%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1.000 Latino/Latina Race0.453 White/Caucasian 28 (77.8%) 3 (50.0%) 4 (66.7%) 6 (100.0%) 6(100.0%) 4 (66.7%) 5 (83.3%) Black/African 3 (8.3%) 2 (33.3%) 1 (16.7%)0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) American Other/Unknown  4 (11.1%) 1(16.7%) 1 (16.7%) 0 (0.0%) 0 (0.0%) 1 (16.7%) 1 (16.7%) Height, cm 165.7± 10.1 161.0 ± 12.9 164.9 ± 10.9 168.6 ± 7.8  164.7 ± 14.2 171.3 ± 7.8 163.6 ± 5.6  0.585 Weight, kg  62.4 ± 15.9  72.5 ± 27.1 56.3 ± 7.7  66.8± 11.0  62.0 ± 15.5 61.9 ± 9.0  54.9 ± 16.8 0.425 Body mass 22.6 ± 5.027.2 ± 8.1 20.8 ± 3.2 23.4 ± 3.2 22.6 ± 4.8 21.0 ± 2.0 20.3 ± 4.8 0.157index, kg/m² * P-values for continuous variables were calculated byANOVA for parametric analysis or Kruskal-Wallis test for non-parametricanalysis. P-values for categorical variables were calculated by Fisher'sexact test.

Example 2—Safety and Adverse Events

The purpose of this example was to describe and evaluate the safety ofthe udenafil compositions administered in the study described in Example1.

Tables 3-6 present numbers of subjects reporting at least one AE; dataare presented by treatment group. The counts are presented by AEcategory (Table 3) and by preferred term (Table 6). Tables 3-6 reportall AEs by category (Table 3), serious AEs (Table 4), non-serious AEs(Table 5), and all AEs by preferred term (Table 6). No serious AEs werereported.

TABLE 3 Adverse Events by Category 37.5 mg 37.5 mg 87.5 mg 87.5 mg 125mg Exercise daily twice daily daily twice daily daily testing only AECategory (N = 6) (N = 6) (N = 6) (N = 6) (N = 6) (N = 6) SubjectsReporting at Least One 5 (83%) 6 (100%) 6 (100%) 5 (83%) 6 (100%)  1(17%) Adverse Event Allergy/Immunology 1 (17%) 0 (0%) 1 (17%) 0 (0%) 0(0%) 0 (0%) Auditory/ocular 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)Cardiovascular 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)  1 (17%)Endocrine/metabolic 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (17%) 0 (0%)Gastrointestinal 2 (33%) 1 (17%) 1 (17%) 1 (17%) 3 (50%) 0 (0%)Hematological 0 (0%) 1 (17%) 0 (0%) 0 (0%) 1 (17%) 0 (0%)Hepatobiliary/pancreas 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)Infection 0 (0%) 0 (0%) 0 (0%) 1 (17%) 0 (0%) 0 (0%)Musculoskeletal/skin 1 (17%) 1 (17%) 1 (17%) 2 (33%) 2 (33%) 0 (0%)Neurological/psychiatric 3 (50%) 3 (50%) 5 (83%) 2 (33%) 5 (83%) 0 (0%)Pulmonary/upper respiratory 2 (33%) 3 (50%) 1 (17%) 1 (17%) 1 (17%) 0(0%) Renal/genitourinary 0 (0%) 2 (33%) 1 (17%) 0 (0%) 0 (0%) 0 (0%)Sexual/reproductive function 0 (0%) 0 (0%) 0 (0%) 2 (33%) 2 (33%) 0 (0%)Vascular 1 (17%) 2 (33%) 4 (67%) 1 (17%) 1 (17%) 0 (0%) Other 0 (0%) 2(33%) 4 (67%) 3 (50%) 2 (33%) 0 (0%) At each level of summation,subjects reporting more than one adverse event are counted only once. N= number of subjects in each cohort. n(%) = number and percentage ofsubjects in category and cohort (n/N × 100)

TABLE 4 Serious Adverse Events 37.5 mg 37.5 mg 87.5 mg 87.5 mg 125 mgExercise daily twice daily daily twice daily daily testing only AECategory (N = 6) (N = 6) (N = 6) (N = 6) (N = 6) (N = 6) SubjectsReporting at Least One 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) AdverseEvent Serious adverse events were not reported for this trial. At eachlevel of summation, subjects reporting more than one adverse event arecounted only once. N = number of subjects in each cohort. n(%) = numberand percentage of subjects in category and cohort (n/N × 100)

TABLE 5 Non-Serious Adverse Events 37.5 mg 37.5 mg 87.5 mg 87.5 mg 125mg Exercise daily twice daily daily twice daily daily testing only AECategory (N = 6) (N = 6) (N = 6) (N = 6) (N = 6) (N = 6) SubjectsReporting at Least One 5 (83%) 6 (100%) 6 (100%) 5 (83%) 6 (100%) 1(17%) Adverse Event At each level of summation, subjects reporting morethan one adverse event are counted only once. N = number of subjects ineach, cohort. n(%) = number and percentage of subjects in category andcohort (n/N × 100)

TABLE 6 Adverse Events by Preferred Term 37.5 mg 37.5 mg 87.5 mg 87.5 mg125 mg Exercise daily twice daily daily twice daily daily testing onlyPreferred Term (N = 6) (N = 6) (N = 6) (N = 6) (N = 6) (N = 6) SubjectsReporting at Least 5 (83%) 6 (100%) 6 (100%) 5 (83%) 6 (100%)  1 (17%)One Adverse Event Abdominal discomfort 1 (17%) 0 (0%) 0 (0%) 1 (17%) 1(17%) 0 (0%) Abdominal pain upper 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (17%) 0(0%) Back pain 0 (0%) 0 (0%) 0 (0%) 1 (17%) 0 (0%) 0 (0%) Chest pain 0(0%) 0 (0%) 0 (0%) 0 (0%) 1 (17%) 0 (0%) Diarrhoea 0 (0%) 0 (0%) 0 (0%)0 (0%) 1 (17%) 0 (0%) Dizziness 0 (0%) 0 (0%) 0 (0%) 1 (17%) 1 (17%) 0(0%) Dry mouth 0 (0%) 0 (0%) 1 (17%) 0 (0%) 0 (0%) 0 (0%) Dysmenorrhoea0 (0%) 1 (17%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) Dyspnoea 1 (17%) 1 (17%) 0(0%) 0 (0%) 0 (0%) 0 (0%) Epistaxis 0 (0%) 1 (17%) 0 (0%) 0 (0%) 2 (33%)0 (0%) Face oedema 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (17%) 0 (0%) Fatigue 0(0%) 1 (17%) 0 (0%) 1 (17%) 0 (0%) 0 (0%) Flushing 1 (17%) 2 (33%) 4(67%) 2 (33%) 1 (17%) 0 (0%) Head injury 0 (0%) 0 (0%) 1 (17%) 0 (0%) 0(0%) 0 (0%) Headache 3 (50%) 4 (67%) 4 (67%) 4 (67%) 5 (83%) 0 (0%)Injection site pain 1 (17%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)Lacrimation increased 0 (0%) 0 (0%) 1 (17%) 0 (0%) 0 (0%) 0 (0%)Migraine 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (17%) 0 (0%) Motion sickness 0(0%) 0 (0%) 1 (17%) 0 (0%) 0 (0%) 0 (0%) Myalgia 0 (0%) 1 (17%) 0 (0%) 0(0%) 0 (0%) 0 (0%) Nasal congestion 3 (50%) 2 (33%) 2 (33%) 1 (17%) 1(17%) 0 (0%) Nasopharyngitis 0 (0%) 1 (17%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)At each level of summation, subjects reporting more than one adverseevent are counted only once. N = number of subjects in each cohort. n(%)= number and percentage of subjects in category and cohort (n/N × 100)

Table 7 presents narratives for all adverse events (limited tonon-serious at the moment of writing) classified by cohort, subject, AEterm, and preferred term.

TABLE 7 Sub- Related ject Adverse Event Term// Onset Resolution to StudyCohort ID* Preferred Term Date Date Severity Drug Outcome Med.¹ Disc.²37.5 mg T12 Nausea // Nausea Aug. 5, 2014 Aug. 5, 2014 Moderate PossiblyResolved without sequelae No No daily Nausea // Nausea Mild NoneResolved without sequelae No NA Headache // Headache Aug. 2, 2014 Aug.2, 2014 Mild Possibly Resolved without sequelae No No Headache //Headache Aug. 5, 2014 Aug. 5, 2014 Moderate Possibly Resolved withoutsequelae No No headache // Headache Aug. 6, 2014 Aug. 7, 2014 ModeratePossibly Resolved without sequelae No NA Headache // Headache Aug. 4,2014 Aug. 4, 2014 Moderate Possibly Resolved without sequelae No Noheadache // Headache Aug. 7, 2014 Aug. 7, 2014 Moderate PossiblyResolved without sequelae No NA Stuffy nose // Aug. 22, 2014 Aug. 29,2014 Mild None Resolved without sequelae No NA Nasal congestion T13Stomach discomfort // Aug. 1, 2014 Aug. 1, 2014 Moderate None Resolvedwithout sequelae No No Abdominal discomfort Headache // Headache Aug. 2,2014 Aug. 5, 2014 Moderate Possibly Resolved without sequelae No NoHeadache // Headache Aug. 7, 2014 Moderate Possibly Resolved withoutsequelae No No Headaches // Headache Mild Possibly Ongoing Yes NAShortness of breath // Aug. 1, 2014 Aug. 1, 2014 Severe None Resolvedwithout sequelae No No Dyspnoea Congestion (Nose) // Nasal Aug. 5, 2014Moderate Possibly Resolved without sequelae No No congestion T14Flushing // Flushing Aug. 1, 2014 Aug. 1, 2014 Mild Probably Resolvedwithout sequelae No No Flushing // Flushing Aug. 2, 2014 Aug. 3, 2014Mild Probably Resolved without sequelae No No Headache // Headache Aug.1, 2014 Aug. 1, 2014 Moderate Possibly Resolved without sequelae Yes NoT15 Pain/other // Injection Aug. 5, 2014 Aug. 8, 2014 Moderate NoneResolved without sequelae Yes No site pain T16 nasal congestion // NasalAug. 4, 2014 Aug. 5, 2014 Mild None Resolved without sequelae No Nocongestion 37.5 mg T21 Nose bleed // Epistaxis Moderate None Resolvedwithout sequelae Yes NA twice daily 37.5 mg T22 Shortness of breath //Nov. 5, 2014 Nov. 5, 2014 Moderate None Resolved without sequelae Yes NAtwice Dyspnoea daily upper respiratory Nov. 2, 2014 Mild None Resolvedwithout sequelae No NA infection // Upper respiratory tract infectionFacial flushing // Flushing Aug. 9, 2014 Aug. 9, 2014 Mild PossiblyResolved without sequelae No No T23 Headache // Headache Aug. 8, 2014Aug. 9, 2014 Mild Possibly Resolved without sequelae No No congestion(stuffy nose) // Aug. 8, 2014 Aug. 8, 2014 Mild Possibly Resolvedwithout sequelae No No Nasal congestion cold/congestion // Sep. 14, 2014Sep. 19, 2014 Mild None Resolved without sequelae No NA NasopharyngitisMenstrual Cramps // Aug. 11, 2014 Aug. 16, 2014 Mild None Resolvedwithout sequelae Yes No Dysmenorrhoea Facial flushing // Flushing Aug.10, 2014 Aug. 10, 2014 Mild Possibly Resolved without sequelae No No T24Nausea // Nausea Aug. 10, 2014 Aug. 10, 2014 Mild Possibly Resolvedwithout sequelae No No Nausea // Nausea Aug. 11, 2014 Aug. 11, 2014 MildPossibly Resolved without sequelae No No Soreness in chest and Aug. 10,2014 Aug. 11, 2014 Mild Possibly Resolved without sequelae No No arms //Myalgia Headache // Headache Aug. 8, 2014 Aug. 8, 2014 Mild PossiblyResolved without sequelae No No Headache // Headache Mild PossiblyResolved without sequelae Yes NA Congestion (stuffy nose) // Aug. 10,2014 Aug. 10, 2014 Mild Possibly Resolved without sequelae No No Nasalcongestion Sponatenous penile Aug. 11, 2014 Aug. 11, 2014 Mild PossiblyResolved without sequelae No No erection // Spontaneous penile erectionSpontaneous penile Aug. 14, 2014 Aug. 14, 2014 Mild Possibly Resolvedwithout sequelae No NA erection // Spontaneous penile erection T25Headache // Headache Aug. 8, 2014 Aug. 8, 2014 Mild Possibly Resolvedwithout sequelae No No T26 Headache // Headache Aug. 9, 2014 Aug. 9,2014 Mild Possibly Resolved without sequelae Yes No Sinus pain // SinusAug. 9, 2014 Nov. 18, 2014 Mild Probably Resolved without sequelae No Noheadache Headache // Headache Aug. 10, 2014 Sep. 22, 2014 ModerateProbably Resolved without sequelae Yes No Fatigue // Fatigue Aug. 9,2014 Aug. 10, 2014 Mild Possibly Resolved without sequelae No No 87.5 mgT31 headache // Headache Aug. 15, 2014 Aug. 15, 2014 Mild ProbablyResolved without sequelae No No daily headache // Headache Aug. 17, 2014Aug. 17, 2014 Mild Probably Resolved without sequelae No No headache //Headache Aug. 18, 2014 Aug. 18, 2014 Moderate Probably Resolved withoutsequelae No No congestion (stuffy nose) // Aug. 15, 2014 Aug. 21, 2014Mild Probably Resolved without sequelae No No Sinus congestion Facialflushing // Flushing Aug. 18, 2014 Aug. 18, 2014 Mild Probably Resolvedwithout sequelae No No spotty vision // Vision Aug. 15, 2014 Aug. 15,2014 Mild None Resolved without sequelae No No blurred T32 motionsickness // Motion Aug. 15, 2014 Aug. 15, 2014 Mild Possibly Resolvedwithout sequelae No No sickness headache // Headache Aug. 15, 2014 Aug.15, 2014 Mild Probably Resolved without sequelae Yes No headache //Headache Aug. 16, 2014 Aug. 16, 2014 Mild Probably Resolved withoutsequelae No No headache // Headache Aug. 17, 2014 Aug. 17, 2014 MildProbably Resolved without sequelae No No dry mouth // Dry mouth Aug. 16,2014 Aug. 16, 2014 Mild Possibly Resolved without sequelae No No T33Head Injury // Head injury Aug. 21, 2014 Aug. 22, 2014 Mild NoneResolved without sequelae Yes NA facial flushing // Flushing Aug. 16,2014 Aug. 22, 2014 Mild Probably Resolved without sequelae No No tearing// Lacrimation Aug. 16, 2014 Aug. 22, 2014 Mild None Resolved withoutsequelae No No increased T34 Sleepiness // Somnolence Aug. 16, 2014 Aug.25, 2014 Mild Possibly Resolved without sequelae No No Spontaneouspenile Aug. 20, 2014 Aug. 20, 2014 Mild Possibly Resolved withoutsequelae No No erection // Spontaneous penile erection Facial Flushing// Flushing Aug. 16, 2014 Aug. 21, 2014 Mild Possibly Resolved withsequelae No No T35 headache // Headache Aug. 15, 2014 Aug. 15, 2014 MildProbably Resolved without sequelae No No 87.5 mg headache // HeadacheAug. 16, 2014 Aug. 16, 2014 Mild Probably Resolved without sequelae NoNo daily stuffy nose // Sep. 20, 2014 Sep. 23, 2014 Moderate NoneResolved without sequelae No NA Nasal congestion T36 Nasal congestion //Nasal Aug. 19, 2014 Aug. 21, 2014 Mild Possibly Resolved withoutsequelae Yes No congestion Flushing // Flushing Aug. 15, 2014 Aug. 15,2014 Mild Probably Resolved without sequelae No No Headache // HeadacheAug. 15, 2014 Aug. 15, 2014 Mild Possibly Resolved without sequelae NoNo 87.5 mg T42 Nausea/vomiting // Nausea Aug. 26, 2014 Aug. 26, 2014Mild Possibly Resolved without sequelae No No twice daily Stomachdiscomfort // Aug. 22, 2014 Aug. 22, 2014 Mild Possibly Resolved withsequelae No No Abdominal discomfort Facial flushing // Flushing Aug. 26,2014 Aug. 26, 2014 Mild Probably Resolved without sequelae No NoHeadache // Headache Aug. 23, 2014 Aug. 23, 2014 Mild Probably Resolvedwithout sequelae No No Headache // Headache Aug. 25, 2014 Aug. 25, 2014Mild Probably Resolved without sequelae No No Headache // Headache Aug.24, 2014 Aug. 24, 2014 Mild Probably Resolved without sequelae No NoHeadache // Headache Aug. 26, 2014 Aug. 26, 2014 Mild Probably Resolvedwithout sequelae No No T43 headache // Headache Aug. 22, 2014 Aug. 22,2014 Moderate Possibly Resolved without sequelae No No headache //Headache Aug. 23, 2014 Aug. 23, 2014 Mild Possibly Resolved withoutsequelae No No headache // Headache Aug. 24, 2014 Aug. 24, 2014 MildPossibly Resolved without sequelae No No T44 Stuffy nose // Aug. 22,2014 Aug. 22, 2014 Mild Possibly Resolved without sequelae No No Nasalcongestion Stuffy nose // Aug. 25, 2014 Aug. 25, 2014 Mild PossiblyResolved without sequelae No No Nasal congestion Stuffy nose // Aug. 25,2014 Aug. 25, 2014 Mild Possibly Resolved without sequelae No No Nasalcongestion spontaneous penile Aug. 21, 2014 Aug. 21, 2014 Mild PossiblyResolved without sequelae No No erection // Spontaneous penile erection87.5 mg Spontaneous penile Aug. 21, 2014 Aug. 21, 2014 Mild PossiblyResolved without sequelae No No twice erection // Spontaneous dailypenile erection Spontaneous penile Aug. 22, 2014 Aug. 22, 2014 MildPossibly Resolved without sequelae No No erection // Spontaneous penileerection spontaneous penile Aug. 25, 2014 Aug. 25, 2014 Mild PossiblyResolved without sequelae No No erection // Spontaneous penile erectionSpontaneous penile Aug. 26, 2014 Aug. 26, 2014 Mild Possibly Resolvedwithout sequelae No No erection // Spontaneous penile erection Headache// Headache Aug. 21, 2014 Aug. 21, 2014 Mild Possibly Resolved withoutsequelae No No Headache // Headache Aug. 22, 2014 Aug. 22, 2014 MildPossibly Resolved without sequelae No No headache // Headache Aug. 23,2014 Aug. 23, 2014 Mild Possibly Resolved without sequelae No Noheadache // Headache Aug. 24, 2014 Aug. 24, 2014 Mild Possibly Resolvedwithout sequelae No No T45 spontaneous penile Aug. 31, 2014 Aug. 31,2014 Mild Possibly Resolved without sequelae No No erection //Spontaneous penile erection T46 sinusitis // Sinusitis Aug. 26, 2014Moderate None Ongoing No No back pain // Back pain Aug. 31, 2014 Sep. 5,2014 Mild Possibly Resolved without sequelae No No flushing // FlushingAug. 30, 2014 Aug. 31, 2014 Mild Possibly Resolved without sequelae NoNo flushing // Flushing Sep. 1, 2014 Sep. 1, 2014 Mild Possibly Resolvedwithout sequelae No No flushing // Flushing Sep. 2, 2014 Sep. 2, 2014Mild Possibly Resolved without sequelae No No flushing // Flushing Sep.2, 2014 Sep. 3, 2014 Mild Possibly Resolved without sequelae No NoHeadache// Headache Aug. 29, 2014 Sep. 5, 2014 Mild Possibly Resolvedwithout sequelae Yes No Dizziness // Dizziness Aug. 30, 2014 Aug. 30,2014 Mild Possibly Resolved with sequelae No No flushing // FlushingAug. 31, 2014 Aug. 31, 2014 Mild Probably Resolved without sequelae NoNo 87.5 mg Fatigue // Fatigue Aug. 30, 2014 Sep. 1, 2014 Mild PossiblyResolved without sequelae No No twice daily edema // Oedema Sep. 2, 2014Mild Possibly Ongoing No No 125 mg T51 headache // Headache Feb. 9, 2015Mild None Resolved without sequelae Yes NA daily T52 Increased frequencyof Nov. 7, 2014 Nov. 8, 2014 Mild Possibly Resolved without sequelae NoNo spontaneous penile erections // Spontaneous penile erection T53Diarrhea // Diarrhoea Dec. 6, 2014 Dec. 6, 2014 Mild Possibly Resolvedwithout sequelae No No Epistaxis // Epistaxis Dec. 7, 2014 Dec. 7, 2014Mild None Resolved without sequelae No No Headache // Headache Dec. 3,2014 Dec. 3, 2014 Mild Possibly Resolved without sequelae No NoSpontaneous penile Dec. 4, 2014 Dec. 4, 2014 Mild Possibly Resolvedwithout sequelae No No erection // Spontaneous penile erection Flushing// Flushing Dec. 4, 2014 Dec. 8, 2014 Mild Probably Resolved withoutsequelae No No T54 Headache // Headache Oct. 10, 2014 Oct. 10, 2014Moderate Possibly Resolved without sequelae No No headache // HeadacheOct. 12, 2014 Oct. 13, 2014 Mild Possibly Resolved without sequelae YesNo headaches // Headache Oct. 13, 2014 Moderate Possibly Ongoing Yes NoDizziness // Dizziness Oct. 13, 2014 Oct. 13, 2014 Moderate PossiblyResolved without sequelae Yes No Stuffy nose (congestion) // Oct. 11,2014 Mild Possibly Ongoing No No Nasal congestion Nose bleed //Epistaxis Oct. 13, 2014 Oct. 13, 2014 Mild Possibly Resolved withoutsequelae No No itchy throat // Oct. 30, 2014 Oct. 30, 2014 Moderate NoneResolved without sequelae Yes NA Throat irritation T55 Nausea // NauseaJan. 13, 2015 Jan. 14, 2015 Moderate None Resolved without sequelae YesNA Swollen/puffy cheeks // Nov. 29, 2014 Nov. 29, 2014 Mild NoneResolved without sequelae No No Face oedema headache // Headache Nov.25, 2014 Nov. 25, 2014 Mild Possibly Resolved without sequelae No No 125mg Headache // Headache Nov. 27, 2014 Nov. 27, 2014 Mild PossiblyResolved without sequelae No No daily Headache // Headache Nov. 28, 2014Nov. 28, 2014 Mild Possibly Resolved without sequelae No No Headache //Headache Nov. 30, 2014 Nov. 30, 2014 Mild Possibly Resolved withoutsequelae No NA Migraine Headache // Jan. 12, 2015 Jan. 14, 2015 ModerateNone Resolved without sequelae Yes NA Migraine T56 Stomach discomfort //Sep. 8, 2014 Sep. 8, 2014 Mild Possibly Resolved without sequelae No NoAbdominal discomfort Stomach discomfort // Sep. 6, 2014 Sep. 10, 2014Mild Possibly Resolved with sequelae No No Abdominal pain upper Stomachdiscomfort // Sep. 7, 2014 Sep. 7, 2014 Mild Possibly Resolved withoutsequelae No No Abdominal discomfort Stomach discomfort // Sep. 9, 2014Sep. 9, 2014 Mild Possibly Resolved without sequelae No No Abdominaldiscomfort Chest pain // Chest pain Sep. 6, 2014 Sep. 7, 2014 MildPossibly Resolved with sequelae No No Rash // Rash Sep. 7, 2014 Sep. 10,2014 Mild Possibly Resolved without sequelae No No Chest pain // Chestpain Sep. 6, 2014 Sep. 6, 2014 Mild None Resolved without sequelae No NoRash // Rash Sep. 8, 2014 Sep. 8, 2014 Mild None Resolved withoutsequelae No No Rash // Rash Sep. 9, 2014 Sep. 9, 2014 Mild None Resolvedwithout sequelae No No Rash // Rash Sep. 11, 2014 Sep. 11, 2014 MildNone Resolved without sequelae No No Rash // Rash Sep. 12, 2014 Sep. 12,2014 Mild None Resolved without sequelae No No Headache // Headache Sep.6, 2014 Sep. 6, 2014 Mild Probably Resolved with sequelae Yes NoHeadache // Headache Sep. 7, 2014 Sep. 7, 2014 Mild Possibly Resolvedwithout sequelae Yes No Headache // Headache Sep. 8, 2014 Sep. 8, 2014Mild Possibly Resolved without sequelae No No Headache // Headache Sep.9, 2014 Sep. 9, 2014 Mild Probably Resolved without sequelae Yes NoHeadache // Headache Sep. 10, 2014 Sep. 10, 2014 Mild Probably Resolvedwithout sequelae Yes No Exer- C2 Ventricular arrhythmia // Dec. 11, 2014Dec. 11, 2014 Mild None Resolved without sequelae No NA cise Ventriculararrhythmia test- ing only Ventricular Tachycardia // Dec. 15, 2014 Dec.15, 2014 Mild None Resolved without sequelae No NA Ventriculartachycardia

Table 8 presents numbers of subjects with number of AEs≥n, where n=1, 2,. . . , 6, by treatment group.

TABLE 8 Adverse Events by Treatment Group 37.5 mg 37.5 mg 87.5 mg 87.5mg 125 mg Exercise N (%) of Subjects daily twice daily daily twice dailydaily testing only Reporting at Least: (N = 6) (N = 6) (N = 6) (N = 6)(N = 6) (N = 6) 1 event 5 (83%)  6 (100%) 6 (100%) 5 (83%)  6 (100%) 1(17%) 2 events 3 (50%) 4 (67%) 6 (100%) 4 (67%) 4 (67%) 1 (17%) 3 events3 (50%) 4 (67%) 6 (100%) 4 (67%) 4 (67%) 0 (0%) 4 events 2 (33%) 3 (50%)2 (33%) 3 (50%) 4 (67%) 0 (0%) 5 events 2 (33%) 2 (33%) 2 (33%) 3 (50%)4 (67%) 0 (0%) 6 events 2 (33%) 1 (17%) 1 (17%) 3 (50%) 3 (50%) 0 (0%)

Tables 9-12 present AEs by preferred term (similar to Table 6), butadditionally report the number of subjects with an AE and the number ofAEs (Table 9), the number of AE events/subjects grouped by treatmentgroup and by related (including possibly or probably) vs. not related tothe study drug (Table 10), mild vs. moderate/severe (Table 11), andexpected vs. unexpected AEs (Table 12).

TABLE 9 Adverse Events by Preferred Term Preferred 37.5 mg 87.5 mgExercise Term, 37.5 mg twice 87.5 mg twice 125 mg testing #Events dailydaily daily daily daily only (#Subjects) (N = 6) (N = 6) (N = 6) (N = 6)(N = 6) (N = 6) Abdominal 1 (1) 0 (0) 0 (0) 1 (1) 3 (1) 0 (0) discomfortAbdominal 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) pain upper Back pain 0 (0)0 (0) 0 (0) 1 (1) 0 (0) 0 (0) Chest pain 0 (0) 0 (0) 0 (0) 0 (0) 2 (1) 0(0) Diarrhoea 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) Dizziness 0 (0) 0 (0)0 (0) 1 (1) 1 (1) 0 (0) Dry mouth 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0)Dysmenor- 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) rhoea Dyspnoea 1 (1) 1 (1)0 (0) 0 (0) 0 (0) 0 (0) Epistaxis 0 (0) 1 (1) 0 (0) 0 (0) 2 (2) 0 (0)Face oedema 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) Fatigue 0 (0) 1 (1) 0(0) 1 (1) 0 (0) 0 (0) Flushing 2 (1) 2 (2) 4 (4) 6 (2) 1 (1) 0 (0) Headinjury 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) Headache 9 (3) 6 (4) 9 (4) 12(4)  14 (5)  0 (0) Injection 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) sitepain Lacrimation 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) increased Migraine0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) Motion 0 (0) 0 (0) 1 (1) 0 (0) 0 (0)0 (0) sickness Myalgia 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) Nasal 3 (3) 2(2) 2 (2) 3 (1) 1 (1) 0 (0) congestion Nasophar- 0 (0) 1 (1) 0 (0) 0 (0)0 (0) 0 (0) yngitis Nausea 2 (1) 2 (1) 0 (0) 1 (1) 1 (1) 0 (0) Oedema 0(0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) Rash 0 (0) 0 (0) 0 (0) 0 (0) 5 (1) 0(0) Sinus 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) congestion Sinus 0 (0) 1(1) 0 (0) 0 (0) 0 (0) 0 (0) headache Sinusitis 0 (0) 0 (0) 0 (0) 1 (1) 0(0) 0 (0) Somnolence 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) Spontaneous 0(0) 2 (1) 1 (1) 6 (2) 2 (2) 0 (0) penile erection Throat 0 (0) 0 (0) 0(0) 0 (0) 1 (1) 0 (0) irritation Upper 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0(0) respiratory tract infection Ventricular 0 (0) 0 (0) 0 (0) 0 (0) 0(0) 1 (1) arrhythmia Ventricular 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1)tachycardia Vision 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) blurred

TABLE 10 Related and Unrelated AEs Preferred 37.5 mg daily 37.5 mg twicedaily 87.5 mg daily 87.5 mg twice daily 125 mg daily Exercise only Term,(N = 6) (N = 6) (N = 6) (N = 6) (N = 6) (N = 6) #Events Drug Not DrugNot Drug Not Drug Not Drug Not Drug Not (#Subjects) related* relatedrelated* related related* related related* related related* relatedrelated* related Abdominal 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0(0) 3 (1) 0 (0) 0 (0) 0 (0) discomfort Abdominal 0 (0) 0 (0) 0 (0) 0 (0)0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) pain upper Back pain 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)Chest pain 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 1 (1) 0(0) 0 (0) Diarrhoea 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1(1) 0 (0) 0 (0) 0 (0) Dizziness 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1(1) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) Dry mouth 0 (0) 0 (0) 0 (0) 0 (0) 1(1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Dysmenor- 0 (0) 0 (0) 0(0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) rhoea Dyspnoea0 (0) 1 (1) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)Epistaxis 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 1 (1) 0(0) 0 (0) Face oedema 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0(0) 1 (1) 0 (0) 0 (0) Fatigue 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 1 (1)0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Flushing 2 (1) 0 (0) 2 (2) 0 (0) 4 (4) 0(0) 6 (2) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) Head injury 0 (0) 0 (0) 0 (0) 0(0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Headache 9 (3) 0 (0)6 (4) 0 (0) 9 (4) 0 (0) 12 (4)  0 (0) 13 (4)  1 (1) 0 (0) 0 (0)Injection 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0(0) 0 (0) site pain Lacrimation 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) increased Migraine 0 (0) 0 (0) 0 (0) 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) Motion 0 (0) 0 (0) 0(0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) sicknessMyalgia 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0(0) 0 (0) Nasal 1 (1) 2 (2) 2 (2) 0 (0) 1 (1) 1 (1) 3 (1) 0 (0) 1 (1) 0(0) 0 (0) 0 (0) congestion Nasophar- 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0)0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) yngitis Nausea 1 (1) 1 (1) 2 (1) 0(0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) Oedema 0 (0) 0 (0) 0(0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Rash 0 (0) 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 4 (1) 0 (0) 0 (0) Sinus 0(0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)congestion Sinus 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0(0) 0 (0) 0 (0) headache Sinusitis 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0(0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) Somnolence 0 (0) 0 (0) 0 (0) 0 (0) 1(1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Spontaneous 0 (0) 0 (0) 2(1) 0 (0) 1 (1) 0 (0) 6 (2) 0 (0) 2 (2) 0 (0) 0 (0) 0 (0) penileerection Throat 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1(1) 0 (0) 0 (0) irritation Upper 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) respiratory tract infectionVentricular 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)0 (0) 1 (1) arrhythmia Ventricular 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) tachycardia Vision 0 (0) 0 (0) 0 (0) 0(0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) blurred Total 13(3)  6 (4) 17 (5)  5 (3) 19 (6)  4 (3) 33 (5)  1 (1) 26 (5)  11 (5)  0(0) 2 (1) *Drug related = possibly related, probably related or relatedto study drug Out of all 36 study subjects, none had adverse eventsrelated to the study drug, and 11, 21 and 17 subjects had adverse eventsthat were probably related, possibly related and unrelated to the studydrug, respectively.

TABLE 11 AEs by Severity Preferred 37.5 mg daily 37.5 mg twice daily87.5 mg daily 87.5 mg twice daily 125 mg daily Exercise only Term, (N =6) (N = 6) (N = 6) (N = 6) (N = 6) (N = 6) #Events Moderate/ Moderate/Moderate/ Moderate/ Moderate/ Moderate/ (#Subjects) Mild severe Mildsevere Mild severe Mild severe Mild severe Mild severe Abdominal 0 (0) 1(1) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 3 (1) 0 (0) 0 (0) 0 (0)discomfort Abdominal 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1(1) 0 (0) 0 (0) 0 (0) pain upper Back pain 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Chest pain 0 (0) 0 (0) 0 (0) 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 2 (1) 0 (0) 0 (0) 0 (0) Diarrhoea 0 (0) 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0)Dizziness 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 1 (1) 0(0) 0 (0) Dry mouth 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0(0) 0 (0) 0 (0) 0 (0) Dysmenor- 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) rhoea Dyspnoea 0 (0) 1 (1) 0 (0) 1 (1)0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Epistaxis 0 (0) 0 (0) 0(0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 2 (2) 0 (0) 0 (0) 0 (0) Face oedema 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0)Fatigue 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0(0) 0 (0) Flushing 2 (1) 0 (0) 2 (2) 0 (0) 4 (4) 0 (0) 6 (2) 0 (0) 1 (1)0 (0) 0 (0) 0 (0) Head injury 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0)0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Headache 2 (2) 7 (3) 5 (4) 1 (1) 8 (4) 1(1) 11 (4)  1 (1) 12 (5)  2 (1) 0 (0) 0 (0) Injection 0 (0) 1 (1) 0 (0)0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) site painLacrimation 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)0 (0) 0 (0) increased Migraine 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)0 (0) 0 (0) 1 (1) 0 (0) 0 (0) Motion 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0)0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) sickness Myalgia 0 (0) 0 (0) 1 (1) 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Nasal 2 (2) 1 (1) 2(2) 0 (0) 1 (1) 1 (1) 3 (1) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) congestionNasophar- 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0(0) 0 (0) yngitis Nausea 1 (1) 1 (1) 2 (1) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0)0 (0) 1 (1) 0 (0) 0 (0) Oedema 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1)0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Rash 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0(0) 0 (0) 5 (1) 0 (0) 0 (0) 0 (0) Sinus 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) congestion Sinus 0 (0) 0 (0) 1(1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) headacheSinusitis 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0(0) 0 (0) Somnolence 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0(0) 0 (0) 0 (0) 0 (0) Spontaneous 0 (0) 0 (0) 2 (1) 0 (0) 1 (1) 0 (0) 6(2) 0 (0) 2 (2) 0 (0) 0 (0) 0 (0) penile erection Throat 0 (0) 0 (0) 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) irritationUpper 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)0 (0) respiratory tract infection Ventricular 0 (0) 0 (0) 0 (0) 0 (0) 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) arrhythmia Ventricular 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0)tachycardia Vision 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0)0 (0) 0 (0) 0 (0) blurred Total 7 (4) 12 (4)  19 (5)  3 (3) 21 (6)  2(2) 32 (5)  2 (2) 31 (6)  6 (2) 2 (1) 0 (0) Out of all 36 studysubjects, 27 had mild adverse events, 13 had moderate and 1 subject hada severe adverse event.

TABLE 12 AEs by Expectedness Preferred 37.5 mg daily 37.5 mg twice daily87.5 mg daily 87.5 mg twice daily 125 mg daily Exercise only Term, (N =6) (N = 6) (N = 6) (N = 6) (N = 6) (N = 6) #Events Ex- Not Ex- Ex- NotEx- Ex- Not Ex- Ex- Not Ex- Ex- Not Ex- Ex- Not Ex- (#Subjects) pectedpected pected pected pected pected pected pected pected pected pectedpected Abdominal 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 3 (1) 0(0) 0 (0) 0 (0) discomfort Abdominal 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) pain upper Back pain 0 (0) 0 (0) 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) Chest pain 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 2 (1) 0 (0) 0 (0)Diarrhoea 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0(0) 0 (0) Dizziness 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0(0) 1 (1) 0 (0) 0 (0) Dry mouth 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Dysmenor- 0 (0) 0 (0) 0 (0) 1 (1) 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) rhoea Dyspnoea 0 (0) 1 (1)0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Epistaxis 0(0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 2 (2) 0 (0) 0 (0)Face oedema 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1)0 (0) 0 (0) Fatigue 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 1 (1) 0(0) 0 (0) 0 (0) 0 (0) Flushing 2 (1) 0 (0) 2 (2) 0 (0) 4 (4) 0 (0) 5 (2)1 (1) 1 (1) 0 (0) 0 (0) 0 (0) Head injury 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Headache 8 (3) 1 (1) 5 (4) 1(1) 9 (4) 0 (0) 11 (3)  1 (1) 13 (5)  1 (1) 0 (0) 0 (0) Injection 0 (0)1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) sitepain Lacrimation 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0(0) 0 (0) 0 (0) increased Migraine 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0(0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) Motion 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) sickness Myalgia 0 (0) 0 (0) 0(0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Nasal 2 (2) 1(1) 2 (2) 0 (0) 2 (2) 0 (0) 3 (1) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0)congestion Nasophar- 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0(0) 0 (0) 0 (0) 0 (0) yngitis Nausea 2 (1) 0 (0) 2 (1) 0 (0) 0 (0) 0 (0)0 (0) 1 (1) 0 (0) 1 (1) 0 (0) 0 (0) Oedema 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) Rash 0 (0) 0 (0) 0 (0) 0 (0) 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 5 (1) 0 (0) 0 (0) Sinus 0 (0) 0 (0) 0 (0) 0(0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) congestion Sinus 0(0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)headache Sinusitis 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0)0 (0) 0 (0) 0 (0) Somnolence 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0(0) 0 (0) 0 (0) 0 (0) 0 (0) Spontaneous 0 (0) 0 (0) 2 (1) 0 (0) 1 (1) 0(0) 6 (2) 0 (0) 2 (2) 0 (0) 0 (0) 0 (0) penile erection Throat 0 (0) 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0)irritation Upper 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0(0) 0 (0) 0 (0) respiratory tract infection Ventricular 0 (0) 0 (0) 0(0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0) arrhythmiaVentricular 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)1 (1) 0 (0) tachycardia Vision 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1) 0 (0)0 (0) 0 (0) 0 (0) 0 (0) 0 (0) blurred Total 14 (4)  5 (3) 15 (5)  7 (5)18 (6)  5 (4) 26 (5)  8 (2) 22 (6)  15 (4)  2 (1) 0 (0) Out of all 36study subjects, 27 subjects had expected and 18 had unexpected adverseevents.

Table 13 focuses on a subset of Table 7 limited to preferred terms forwhich AEs happened more than once (either ≥2 AEs for one subject, or >2subjects with at least one AE) in at least one cohort.

TABLE 13 Events That Occurred More Than Once in One Subject or In MoreThan One Subject Preferred 37.5 mg 87.5 mg Exercise Term, 37.5 mg twice87.5 mg twice 125 mg testing #Events daily daily daily daily daily only(#Subjects) (N = 6) (N = 6) (N = 6) (N = 6) (N = 6) (N = 6) Abdominal 1(1) 0 (0) 0 (0) 1 (1) 3 (1) 0 (0) discomfort Chest pain 0 (0) 0 (0) 0(0) 0 (0) 2 (1) 0 (0) Epistaxis 0 (0) 1 (1) 0 (0) 0 (0) 2 (2) 0 (0)Flushing 2 (1) 2 (2) 4 (4) 6 (2) 1 (1) 0 (0) Headache 9 (3) 6 (4) 9 (4)12 (4)  14 (5)  0 (0) Nasal 3 (3) 2 (2) 2 (2) 3 (1) 1 (1) 0 (0)congestion Nausea 2 (1) 2 (1) 0 (0) 1 (1) 1 (1) 0 (0) Rash 0 (0) 0 (0) 0(0) 0 (0) 5 (1) 0 (0) Spontaneous 0 (0) 2 (1) 1 (1) 6 (2) 2 (2) 0 (0)penile erection

FIG. 1 displays the percent of subjects reporting at least one, three orfive adverse events by treatment group (the numbers are taken from Table6). The cohorts at horizontal axis are sorted from the lowest daily doseat the left (exercise only group; zero dose, though not a placebo) tothe highest one-time dose (125 mg) at the right. The percentages varyfrom 100% to 0% (exercise only group). As expected, the exercise onlygroup features the lowest percentage. The plot doesn't suggest a clearassociation between the dose and percent of subjects reporting AEs.

Example 3—Exercise Testing

The purpose of this example was to evaluate the efficacy of thetreatment protocol described in Example 1 using various exercise testingparameters.

The primary outcome of this arm of the study was maximal VO2 asdetermined by exercise testing. Table 14 summarizes results for the keyoutcome from the exercise testing-peak VO2 (limited to the subjects whoachieved maximum effort) by treatment group. Out of the 36 subjectsenrolled in the trial, 33 reached max effort in the exercise testing ateach of the time points, and 31 subjects at both time points. The firsttwo lines present data for baseline and follow-up measurements, whilethe third line presents differences between the two measurements (changescores, the outcome for this aim). Analysis of variances suggests lackof differences between the change scores (p=0.85).

TABLE 14 Peak VO2 at Maximum Effort, ml/kg/min All 37.5 mg 37.5 mg 87.5mg 87.5 mg 125 mg Exercise N subjects N daily N twice daily N daily Ntwice daily N daily N only P-value Baseline 34 28.5 ± 5.8 6 24.6 ± 6.9 630.4 ± 6.2 6 28.4 ± 6.2 5 28.0 ± 5.2 5 28.6 ± 3.0 6 30.6 ± 6.2 0.542measurement Follow-up 33 28.2 ± 5.8 5 24.7 ± 6.7 6 28.8 ± 8.1 6 27.1 ±5.0 5 28.2 ± 6.0 6 28.6 ± 3.8 5 31. 8 ± 5.0  0.570 measurementDifference, 32 −0.6 ± 3.3 5 −0.8 ± 1.7 6 −1.6 ± 5.1 6 −1.4 ± 2.5 5  0.2± 5.0 5  0.9 ± 2.6 5 −0.3 ± 1.8 0.851 FU − BL P-values were calculatedby ANOVA. The maximum effort was achieved when the respiratory quotientat peak ≥ 1.1.

FIGS. 2 and 3 present the findings for change scores in a visual way(with a positive change indicating an improvement). FIG. 2 displaysindividual change score for each subject with paired measurements(circles) and two lines with mean and median values. The plots don'tsuggest that change scores increase with the dose. FIG. 3 displaysmaximal VO2 values before and after the treatment for each subject andin each cohort.

As expected, baseline and follow-up measurements are stronglycorrelated, with the correlation coefficient >0.8.

An additional outcome, VO2 at anaerobic threshold, was also measured.Similar analyses were performed for this outcome. Results are presentedin Table 15 and FIGS. 4 and 5. Overall results are similar to those formaximal VO2.

TABLE 15 Peak VO2 at Anaerobic Threshold, ml/kg/min All 37.5 mg 37.5 mg87.5 mg 87.5 mg 125 mg Exercise N subjects N daily N twice daily N dailyN twice daily N daily N only P-value Baseline 36 18.6 ± 4.5 6 17.2 ± 5.06 18.0 ± 3.0 6 17.6 ± 5.3 6 18.3 ± 4.6 6 18.8 ± 1.8 6 21.7 ± 6.2 0.570measurement Follow-up 34 18.2 ± 4.4 5 16.3 ± 2.0 6 18.1 ± 3.0 6 16.5 ±4.8 6 16.5 ± 5.2 6 20.0 ± 3.2 5 22.4 ± 5.5 0.135 measurement Difference,34 −0.3 ± 2.6 5 −0.5 ± 4.1 6  0.1 ± 1.0 6 −1.1 ± 1.9 6 −1.7 ± 2.1 6  1.2± 1.9 5  0.1 ± 3.8 0.469 FU − BL P-values were calculated by ANOVA.

Of note, both exercise outcomes (peak VO2 and VO2 at anaerobicthreshold) are highly correlated (with the correlation coefficient ateach visit above 0.7), which may explain similarities in the trend linesin FIGS. 2 and 4.

Example 4—Vascular Function Testing

The primary outcome of vascular function was determined according to anendothelial pulse amplitude tonometry (PAT) index as determined by theEndoPAT® device (Itamar Medical, Caesarea, Israel).

Table 16 summarizes the results for the key outcome from the vascularfunction testing-natural log of Reactive Hyperemia Index (ln RHI) bytreatment group. Out of the 30 subjects enrolled in the treatment armsof the trial, 27 subjects had paired measurements with an acceptablequality (with QC score equal to 3 (the best) or 2). The structure of thetable is similar to the one for exercise variables.

TABLE 16 Natural Log of Reactive Hyperemia Index All 37.5 mg 37.5 mg87.5 mg 87.5 mg 125 mg N subjects N daily N twice daily N daily N twicedaily N daily P-value Baseline 28 0.52 ± 0.28 6 0.48 ± 0.31 6 0.60 ±0.30 6 0.41 ± 0.25 4 0.49 ± 0.12 6 0.63 ± 0.37 0.704 measurementFollow-up 28 0.49 ± 0.28 6 0.51 ± 0.26 6 0.53 ± 0.29 5 0.45 ± 0.31 50.40 ± 0.29 6 0.52 ± 0.34 0.945 measurement Difference, 27 −0.02 ± 0.30 6 0.03 ± 0.47 6 −0.07 ± 0.17  5 0.07 ± 0.22 4 −0.03 ± 0.20  6 −0.10 ±0.38  0.902 FU − BL

FIGS. 6 and 7 present the findings for change scores in a visual way(with a positive change indicating an improvement). FIG. 6 displays theindividual change score for each subject with paired measurements(circles) and two lines with mean and median values. The plots do notsuggest that change scores increase with the dose. FIG. 7 displays lnRHI values before and after the treatment for each subject and in eachcohort.

Baseline and follow-up measurements are moderately correlated, with anoverall correlation coefficient of 0.4.

Of note, both mean baseline and follow-up measurements are close to thecut-off value of 0.51 suggested by the EndoPAT documentation as athreshold between the normal (defined as ln RHI>0.51) and abnormal (lnRHI<0.51) values. Analysis of the data indicates that some patientsshowed as much as a 9.75% improvement in this measure.

Table 17 reports change scores only for secondary EndoPAT outcomes (RHI,Framingham RHI etc; top panel) and other EndoPAT indices. In all cases apositive change suggests a possible improvement.

TABLE 17 Secondary and Other EndoPAT Outcomes, FU − BL All 37.5 mg 37.5mg 87.5 mg 87.5 mg 125 mg N subjects N daily N twice daily N daily Ntwice daily N daily P-value Secondary EndoPAT outcomes Reactive 27 −0.04± 0.56 6  0.03 ± 0.84 6 −0.12 ± 0.30 5 0.12 ± 0.34 4 0.01 ± 0.38 6 −0.21± 0.78 0.895 Hyperemia Index Framingham 27 −0.06 ± 0.39 6 −0.00 ± 0.58 6−0.17 ± 0.19 5 0.04 ± 0.36 4 0.00 ± 0.20 6 −0.13 ± 0.51 0.901 RHIAUC2max_oc: 27  0.51 ± 2.91 6 −0.93 ± 4.37 6 −1.19 ± 1.84 5 3.03 ± 2.494 0.16 ± 1.08 6  1.80 ± 1.18 0.058 Area under the curve to Max-Occlusion/ Control Avg2Max_oc: 27 −0.16 ± 0.79 6 −0.35 ± 1.01 6 −0.33 ±0.26 5 0.17 ± 0.43 4 0.24 ± 0.23 6 −0.32 ± 1.28 0.626 average up to max-Occlusion/ Control Other EndoPAT indices AUC2max_o: 27 −0.26 ± 2.75 6−0.23 ± 2.74 6  0.09 ± 1.45 5 −1.26 ± 4.89  4 −0.51 ± 1.64  6  0.37 ±2.71 0.910 Area under the curve to Max- Occlusion (ratio to baseline)AUCall_o: 27  0.18 ± 3.54 6 −0.01 ± 2.73 6 −0.69 ± 2.17 5 1.66 ± 5.96 40.60 ± 2.95 6 −0.28 ± 3.98 0.864 Area under the curve all- Occlusion(ratio to baseline) AUCall_oc: 27 −0.60 ± 4.93 6 −1.34 ± 6.42 6 −1.19 ±2.00 5 1.88 ± 3.25 4 0.17 ± 4.30 6 −1.84 ± 7.21 0.772 Area under thecurve all- Occlusion/ Control Avg2Max_o: 27  0.04 ± 0.51 6 −0.12 ± 0.286  0.15 ± 0.19 5 0.10 ± 0.69 4 0.03 ± 0.36 6  0.07 ± 0.86 0.930 averageupto max- Occlusion** Avgall_o: 27  0.02 ± 0.40 6  0.02 ± 0.27 6 −0.08 ±0.24 5 0.14 ± 0.67 4 0.09 ± 0.33 6 −0.03 ± 0.49 0.927 average all-Occlusion** Avgall_oc: 27 −0.06 ± 0.54 6 −0.10 ± 0.66 6 −0.13 ± 0.22 50.16 ± 0.36 4 0.05 ± 0.45 6 −0.20 ± 0.84 0.848 average all - Occlusion/Control P-values were calculated by ANOVA. **ratio to baseline

Example 5—Echocardiographic Assessment of Ventricular Performance

The primary outcome of ventricular performance with assessed usingechocardiographic methods and measured according to a myocardialperformance Index (MPI). The MPI is a ventricular geometry-independentmeasure of combined systolic and diastolic ventricular performance(Charles S. Kleinman et al, 2008—Health and Fitness). It is obtained byindexing the sum of isovolumetric contraction and relaxation time toejection time.

Table 18 summarizes results for the key outcome from theEchocardiographic Assessment of Ventricular Performance—Blood Pool MPI.Out of the 30 subjects enrolled in the treatment arms of the trial, 27subjects had paired measurements. The structure of the table is similarto the one for exercise variables. Analysis of the data indicates thatsome patients showed as much as a 21.5% improvement in this measure.

TABLE 18 Blood Pool MPI All 37.5 mg 37.5 mg N subjects N daily N twicedaily N Baseline 29 0.581 ± 0.197 6 0.537 ± 0.304 6 0.496 ± 0.150 6measurement Follow-up 28 0.517 ± 0.165 5 0.504 ± 0.187 6 0.494 ± 0.087 6measurement Difference, 27 −0.059 ± 0.134  5 −0.052 ± 0.166  6 −0.003 ±0.102  6 FU − BL 87.5 mg 87.5 mg 125 mg daily N twice daily N dailyP-value Baseline 0.588 ± 0.158 5 0.548 ± 0.136 6 0.728 ± 0.155 0.305measurement Follow-up 0.512 ± 0.163 6 0.410 ± 0.078 5 0.696 ± 0.2020.058 measurement Difference, −0.076 ± 0.144  5 −0.118 ± 0.090  5 −0.054± 0.180  0.744 FU − BL

FIGS. 8 and 9 present the findings for change scores in a visual way(with a negative change indicating an improvement). FIG. 8 displaysindividual change score for each subject with paired measurements(circles) and two lines with mean and median values. The plots don'tsuggest that change scores increase with the dose. FIG. 9 displays bloodpool MPI index values before and after the treatment for each subjectand in each cohort.

Baseline and follow-up measurements are strongly correlated, with theoverall correlation coefficient of 0.7 (last 2 lines). Of note, bothmean baseline and follow-up measurements are in the elevated area(>0.4).

Tables 19-21 and FIGS. 9-15 report similar results for three otherversions of MPI: Tissue Doppler MPI, and Average IsovolumetricContraction and Relaxation.

TABLE 19 Tissue Doppler MPI All 37.5 mg 37.5 mg N subjects N daily Ntwice daily N Baseline 28 0.760 ± 0.299 6 0.701 ± 0.417 6 0.818 ± 0.3616 measurement Follow-up 28 0.707 ± 0.201 5 0.637 ± 0.206 6 0.729 ± 0.2306 measurement Difference, 26 −0.056 ± 0.198  5 −0.052 ± 0.398  6 −0.089± 0.142  6 FU − BL 87.5 mg 87.5 mg 125 mg daily N twice daily N dailyP-value Baseline 0.804 ± 0.118 4 0.540 ± 0.019 6 0.861 ± 0.323 0.517measurement Follow-up 0.716 ± 0.142 6 0.638 ± 0.168 5 0.822 ± 0.2710.579 measurement Difference, −0.089 ± 0.131  4 0.060 ± 0.068 5 −0.074 ±0.141  0.813 FU − BL

TABLE 20 Average Isovolumic Contraction All 37.5 mg 37.5 mg 87.5 mg 87.5mg 125 mg N subjects N daily N twice daily N daily N twice daily N dailyP-value Baseline 28 115.6 ± 50.5 6 99.2 ± 50.7 6 109.4 ± 51.1 6 122.4 ±36.7 4 84.1 ± 20.3 6 152.4 ± 64.4 0.236 measurement Follow-up 28 107.1 ±41.3 5 86.4 ± 22.7 6 103.6 ± 32.4 6 115.0 ± 32.9 6 83.8 ± 26.4 5 150.5 ±60.5 0.047 measurement Difference, 26  −4.6 ± 28.3 5 −3.5 ± 50.0 6  −5.8± 25.7 6  −7.4 ± 26.5 4  4.1 ± 12.1 5  −8.0 ± 24.6 0.977 FU − BL

TABLE 21 Average Isovolumetric Relaxation All 37.5 mg 37.5 mg 87.5 mg87.5 mg 125 mg N subjects N daily N twice daily N daily N twice daily Ndaily P-value Baseline 28 91.2 ± 22.2 6 83.8 ± 16.1 6 100.8 ± 32.3 693.4 ± 11.0 4 72.3 ± 10.5 6 99.5 ± 25.0 0.236 measurement Follow-up 2892.0 ± 23.8 5 94.0 ± 26.7 6 101.6 ± 40.0 6 86.4 ± 15.3 6 82.4 ± 11.4 596.8 ± 17.4 0.674 measurement Difference, 26  0.1 ± 14.4 5  9.0 ± 11.5 6 0.8 ± 21.2 6 −6.9 ± 10.1 4  5.2 ± 12.6 5 −5.4 ± 11.1 0.354 FU − BL

For these three additional versions of MPI, a negative change alsosuggests a possible improvement and the overall conclusions are similarto those for Blood Pool MPI.

Additionally, because positive outcomes were seen during the shortduration of the studies described in Examples 1-5, administeringudenafil or a pharmaceutically acceptable salt thereof to a Fontanpatient for a longer period of time could produce even more beneficialpharmacodynamic outcomes.

Example 6—Pharmacokinetic Testing

NONMEM version 7.2, R, PDxPOP® 5, Xpose, and Phoenix WinNonlin was usedfor the pharmacokinetic analysis.

Pharmacokinetic analysis was performed on Fontan patients receivingudenafil. FIG. 16 show the results of data evaluation for individualsubjects by dosing cohort, and FIG. 17 shows the concentration profilesof udenafil in the study subjects. Plasma concentrations were determinedat various time points and non-compartmental analysis was performed inpatients and stratified by dosing regimens.

FIGS. 18-20 demonstrate various comparisons among the dosing cohorts.Based on the non-compartment analysis, C_(max) was significantlyincreased in 87.5 mg q12h cohort and 125 mg q24h cohort compared to the37.5 mg q12h or q24h cohorts (FIG. 18).

The 87.5 mg q12h cohort exhibited increased C_(max) compared to its q24hcounterpart (FIG. 18). AUC_(τ) was significantly increased in 87.5 mgq12h cohort and 125 mg q24h cohort compared to the 37.5 mg q12h or q24hcohorts (FIG. 19). AUC₀₋₂₄ was significantly increased in 125 mg q24hcohort compared to the 37.5 mg q24h cohorts. The 87.5 mg q12h cohortshowed increased highest AUC₀₋₂₄ among all the regimens tested (FIG.19). No significant difference was observed in CL/F or V/F among dosingregimens, expect the significant differences between 37.5 mg q24h and87.5 mg q12h (FIG. 20). There was no statistically significantdifference in k_(e), T_(1/2), or T_(max) among all 5 tested dosingregimens.

Population PK Model Development

The population PK analysis was performed using a non-linear mixedeffects modeling approach. This approach estimates the typical value ofparameters and their variances. It was assumed subjects were at steadystate (SS): at a time (t) after dose (D) given at time tD after repeatedadministration of dose D given at interval τ (t≥t_(D)) as PKsamples/udenafil concentrations were taken on study day 6.

As only the drug administration at Day 6 was supplied, it is expectedthat the subjects have taken the drug at regular intervals at home; dueto this a steady state flag will be tested to account for the doseswhich are not available. As stated, it is assumed steady state has beenreached by Day 6, as previous studies of udenafil have stated thatduring multiple dosing, steady state is reached in 5 days, withapparently little additional accumulation occurring after dosing for 7days. If there were missed doses during the study period prior to the PKsampling, this can affect the ability to determine whether steady statecould be assumed or not for the PK profile. If two or more additionaldrug administration dates and times were available prior to the visitwhere the PK samples were taken, then a much better dosing profile couldbe used for analysis.

Structural Model

One- and two-compartment models were explored (based on literature andavailable data). The equation for the Input model for the drug describedoral absorption. For the one-compartment model, the following equationmay apply to the model:

$\frac{dA}{dt} = {{Input} - \left( {k\; 10*A} \right)}$

And considering that CL=k10*V, the following equation may also apply:

$\frac{dC}{dt} = \frac{{Input} - \left( {{CL}*C} \right)}{V}$

The two-compartment model can be described by the following differentialequation:

$\frac{{dX}\; 1}{dt} = {{{ka} \cdot {Xg}} + {k\; {21 \cdot X}\; 2} - {{\left( {{k\; 12} + {kel}} \right) \cdot X}\; 1}}$

Drug Amount in the body after oral administration may be described bythe following differential equation:

Cp=A·e ^(−α·t) +β·e ^(−β·t) +C·e ^(−ka·t)

The robustness of the final model was assessed in PDxPOP® 5 by bootstrapre-sampling (n=1000). Values obtained with the bootstrap (based on allruns with successful minimization) were compared to the parameterestimates from the final model. To evaluate the accuracy of the modelpredictions, normalized prediction distribution errors (NPDE) wasperformed.

Certain a priori information was used in guiding the development of themodels.

One- and two-compartment models with oral absorption input wereevaluated using initial estimates obtained from the literature asdescribed above, and were explored to determine the potential structureof the model. The models were evaluated during the model buildingprocess by using objective function value, level of statisticalsignificance, goodness of fit plots, and standard error.

The only covariate available for analysis was current body weight.Weight was tested as a fixed effect on typical values for clearance andvolume of distribution (e.g., weight has a “fixed effect” on clearance).Median weight in the dataset was 65.3 kg.

The “typical value” for clearance is predicted per 70 kg patient usingweight (WT) in the data set. The estimated THETA(1) and THETA(2) forsubjects of known WT can be directly compared with CL and V values insubjects of “standard” weight, e.g. WTs=70 kg.

Concern is sometimes expressed that scaling parameter values estimatedin children in terms of an adult size standard of 70 kg may bias theestimates, or affect the precision of estimation. There is no basis forthis concern. This can be seen by inspection of the allometric scaledcovariate model which may be re-arranged and is simply a constant thatis determined by whatever weight is chosen for standardization. Theprecision of a parameter estimate will not be changed by multiplying theparameter value by an ad hoc constant. The criteria for covariateequation selection for weight in the model was statistical significance.

FIGS. 21-29 show the results of the pharmacokinetic data analysis.

During the model building process, a number of residual error modelswere evaluated. Proportional and exponential error models were unable torun, these terminated every time. Additive error models were able torun, but the GOF plots showed a poor fit for one-compartment models witha better fit in the two compartment model. The choice was made to use acombined error model for the base model, despite the high CV % in theresidual variability, as this model gave good estimates for otherparameters, 95% CIs and showed a good fit on visual inspection of GOFplots (FIGS. 30-31). It may be possible to control for the high CV % ifall of the doses from days 1-5 were included from each subject in thedataset before the day 6 dose, around which the sampling occurred. It isnot be necessary to do this as the model fit is good as presentlydescribed, but this may further reduce the % CVs.

After comparing observed data and predicted data, a final model wasproduced. GOF plots for the final model are found in FIGS. 32 and 33.

Bootstrap re-sampling was undertaken to compare the parameter estimatesfrom the final model with those determined following 1000 bootstrapruns. In addition: visual predictive checks (plot comparing 95%prediction interval with observed data) and normalized predictiondistribution errors (NPDE) techniques were applied for final modelevaluation. Additionally a visual predictive check was performed.

Udenafil pharmacokinctics were well described by a two-compartment modelwith combined additive and proportional error. Apparent clearance (CL/F)were scaled using current body weight standardized to adult weight, 70kg. Absorption rate constant was estimated as 0.28 h−1 (95% CI0.16-0.39), apparent clearance (CL/F/70 kg) 36 L/h (95% CI 28.5-43.1),central volume of distribution (V2/F) 74 L (95% CI 36.2-112),inter-compartmental clearance (Q/F) 21.1 L (95% CI 10.4-31.8) andperipheral volume of distribution (V3/F) 181 L (95% CI 141-221). Thefinal model was evaluated by bootstrap re-sampling, normalizedprediction distribution errors, and visual predictive check techniques.These techniques demonstrated a good fit of the final covariate model tothe data.

A two-compartment model with absorption rate constant successfullydescribed the pharmacokinetics of udenafil in adolescents with singleventricle physiology after Fontan palliation. There was a statisticallysignificantly influence on apparent clearance (CL/F) when subject bodyweight was standardized to adult weight, 70 kg included in the finalmodel, CL/F L/hr/70 kg.

Example 7—Phase III Study of Udenafil in Fontan Patients

A Phase III study of udenafil in Fontan patients will determine thesafety of udenafil (87.5 mg, twice daily) in an adolescent populationwith single ventrile congenital heart disease palliated with the Fontanprocedure. The study will also evaluate the pharmacodynamics profile ofudenafil over a period of time ranging from at least six months and upto one year. Pharmacodynamic outcomes will include exercise capacity,echocardiographic measures of ventricular function, endothelialfunction, and serum biomarkers, as well as measures of functional healthstatus/quality of life. It is expected that udenafil (87.5 mg, twicedaily) will be safe, and effective for improving exercise capacity andother endpoints of cardiovascular health, as well as improving qualityof life.

Methodology—Randomized, double-blind, placebo-controlled clinical trialof a six month to one-year treatment with an 87.5 mg/twice a day dose in300 subjects between 12 and 19 years of age who have had the Fontansurgery before 5 years of age.

Inclusion Criteria for the study include:

-   -   Males or females age 12-19.    -   Fontan surgery before 5 years of age.

Exclusion Criteria for the study include:

-   -   Height <132 cm.    -   Hospitalization for acute decompensated heart failure within the        last 12 months.    -   Current intravenous inotropic drugs.    -   Undergoing evaluation for heart transplantation or listed for        transplantation.    -   Diagnosis of protein losing enteropathy, plastic bronchitis,        liver cirrhosis.    -   Known Fontan baffle obstruction, branch pulmonary artery        stenosis, or pulmonary vein stenosis resulting in a mean        gradient of >4 mm Hg between the regions proximal and distal to        the obstruction as measured by either catheterization or        echocardiography.    -   Single lung physiology.    -   Severe ventricular dysfunction assessed qualitatively by        clinical echocardiography within 6 months prior to enrollment.    -   Severe valvar regurgitation, ventricular outflow obstruction, or        aortic arch obstruction assessed by clinical echocardiography        within 6 months prior to enrollment.    -   Significant renal, hepatic, gastrointestinal or biliary        disorders that could impair absorption, metabolism or excretion        of orally administered medications.    -   Inability to complete exercise testing at baseline screening.    -   History of PDE-5 inhibitor use within 3 months before study        onset.    -   Use of any other drug to treat pulmonary hypertension within 3        months before study onset.    -   Known intolerance to oral udenafil.    -   Frequent use of medications or other substances that inhibit or        induce CYP3A4.    -   Current use of alpha-blockers or nitrates.    -   Ongoing or planned participation in another research protocol        that would either prevent successful completion of planned study        testing or invalidate its results.    -   Noncardiac medical, psychiatric, and/or social disorder that        would prevent successful completion of planned study testing or        would invalidate its results.    -   Cardiac care, ongoing or planned, at a non-study center that        would impede study completion.    -   For females: Pregnancy at the time of screening, pregnancy        planned before study completion, or refusal to use an acceptable        method of contraception for study duration.    -   Unable to abstain or limit intake of grapefruit juice during the        duration of the trial.    -   Refusal to provide written informed consent/assent.    -   In the opinion of the primary care physician, the subject is        likely to be non-compliant with the study protocol.

The study will include baseline measures of the proposedpharmacodynamics (PD) endpoints as well as quality of life surveys. Forexample, EndoPAT vascular assessment will be completed as the first PDtest following consent. This must be performed in a fasting (frommidnight until after the test), non-caffeinated state. After thevascular assessment, subjects will have a targeted echocardiogram toassess ventricular function. A short break will be given, either afterthe vascular assessment or after the echocardiogram, and a light snackwill be provided. Safety labs will be performed following the vascularassessment, echocardiogram, and break. These will include collection ofblood to evaluate serum creatinine and liver enzyme (aspartatetransaminase and alanine transaminase) levels for all participants, anda urine pregnancy test for female participants. If the pregnancy test ispositive all further testing will be stopped, the patient will not beenrolled into the trial and the result will be conveyed to the subjectand/or guardians by the site-principal investigator in accordance withlocal IRB procedures. After the safety labs, an exercise test will beadministered using a braked cycle ergometer following a ramp protocolpreviously published in the PHN Fontan Cross-Sectional Study. Afterexercise testing, subjects will have completed the baseline testing.Additionally, The Peds QL, cardiac specific Peds QL, and PCQLI will beadministered during the baseline testing visit.

A study coordinator will call each subject weekly for four weeks andthen monthly thereafter to collect adverse events and answer questionsrelated to the study.

At the end of the study, subjects will arrive in a fasting,non-caffeinated state, and first undergo vascular function assessmentincluding repeating the baseline tests as well as the quality of lifesurveys. Follow up with subjects may occur at 30 and 90 days followingend-of-study testing to record any additional adverse events possibly orprobably related to the study drug that may have occurred in the 90 daysfollowing completion of the study protocol.

It is expected that udenafil (87.5 mg bid) in adolescents with Fontanphysiology over a 6-12 month period will be safe and well tolerated,with few, if any, serious adverse events related to udenafil. Theseverity of adverse events is determined according to the CommonTerminology Criteria for Adverse Events (CTCAE) Version 4.0 MedDRA 12.1(http://ctep.cancer.gov). Likewise, the effect of udenafil onpharmacodynamic outcomes including exercise capacity, echocardiographicmeasures of ventricular function, endothelial function, and biomarkersassociated with heart failure is expected to improve over the course oftreatment. The outcomes to be measured to determine the efficacy ofudenafil in this patient population will include:

-   -   Exercise: Change in maximal oxygen consumption from baseline to        end-of-study testing measured using a standardized exercise        test;    -   Echo: Change in myocardial performance index as measured by        pulse wave Doppler echocardiography from baseline to        end-of-study testing;    -   Endothelial Function: Change in log-transformed Reactive        Hyperemia Index derived from the EndoPAT® device; and    -   Biomarkers: Change in serum BNP level from baseline to        end-of-study.

As well as:

-   -   Exercise: Submaximal measures of exercise capacity will be        collected and evaluated.    -   Echo: Measure of systolic and diastolic function will be        collected from a targeted echocardiogram.

The study may also look at outcomes related to ventricular cavity size,eccentricity, and mass; systolic function as estimated using mean dP/dtduring isovolumetric contraction (dP/dtic) and peak systolic annularvelocity (S′) on tissue Doppler; tissue Doppler based estimates ofdiastolic function and MPI; and qualitative and quantitative estimate ofAV valve insufficiency.

It is also expected that functional health status will improve followingadministration of udenafil. The change in functional health status frombaseline to the end of the study may be measured by the full scale PedsQL, Peds QL physical functioning score, Peds QL psychosocial functioningscore, Peds QL cardiac-specific module quality of life score, and/or thepediatric cardiac quality of life inventory (PCQLI) score.

Furthermore, genetic material may be collected during the study toidentify genetic determinants of response to udenafil after the Fontanprocedure in persons with single-ventricle lesions. This will provide anindication of whether specific sub-populations of patients will have amore positive response to udenafil than others. For instance, theresponse to udenafil may be influenced by variants related to thevascular response to udenafil. Variants in the endothelial nitric oxidesynthase gene have been reported to influence the response to sildenafilin patients with erectile dysfunction, although this has not beenstudied for udenafil. Variation in genes that regulate the vascular,inotropic and chronotropic response to exercise may influence theexercise capacity of patients after the Fontan procedure as well as theresponse to udenafil. DNA will be stored to perform future genotypingstudies to analyze the genetic contribution to the response to udenafil.

Additional covariate measures will include, but may not be limited to,age, gender, race/ethnicity, height/weight, ventricular morphology,resting oxygen saturation, baseline pharmacodynamics test results, andcurrent medication use. Observance of these variables will allow for theidentification of associations between a variety of clinical factors andboth safety and PD outcomes.

Data collection will include recording demographic information includingage, gender, race, ethnicity, cardiac anatomy, date of Fontan procedure,presence of a fenestration, degree of atrioventricular valveregurgitation, grade of ventricular function, concomitant medications,and significant co-morbidities. Safety data will reviewed with eachsubject at each study visit and during telephone encounters. Theseevents will be recorded and graded by severity and relationship to thestudy drug based upon established criteria. Two additional telephoneencounters will take place 30 days and 90 days following end-of-studytesting to assess for any adverse events possibly or probably related tothe study drug in the period following the completion of studyprocedures.

Other data collection will include:

-   -   Exercise stress test—Data from the braked cycle ergometry        exercise stress tests will be collected according to protocol        established in the PHN Fontan Cross-Sectional Study 3.    -   Assessment of ventricular performance—Each study echocardiogram        will be stored in a de-identified manner and sent to a core        laboratory, which will perform the data analysis and submit the        measurements to the PHN Data Coordinating Center (DCC).    -   Vascular function testing—De-identified data from EndoPAT®        testing will be collected according to a standardized protocol.        These data will be sent to a vascular core lab, which will        perform the analysis and submit the measurements to the PHN DCC.    -   Biomarkers—Serum for measurement of BNP level will be sent to a        core clinical lab.

Results will be sent directly to the PHN DCC.

-   -   Quality of life survey—Results of the Quality of life surveys        will be submitted to the PHN DCC.    -   Samples for the biorepository—Samples collected for the        biorepository will be shipped directly to the biorepository for        future analysis.

Subjects will be treated with other medications at the discretion oftheir physicians. At the study visits, current medications will berecorded on the study forms. If a subject begins open-label use of anyother PDE-5 inhibitor at any time during the study, withdrawal from thestudy drug is required.

When an individual subject completes the study, the subject's primarycardiologist will be notified, and the study drug will be stopped; thereis no need to wean subjects off of the study drugs. The decision ofwhether to continue the use of an off label PDE-5 inhibitor forindividual subjects will be decided by the subjects and their primarycardiologist.

While certain of the preferred embodiments of the present invention havebeen described and specifically exemplified above, it is not intendedthat the invention be limited to such embodiments. Various modificationsmay be made thereto without departing from the scope and spirit of thepresent invention.

1-30. (canceled)
 31. A method of treating a single ventricle heartdisease (SVHD) patient with udenafil, or a pharmaceutically acceptablesalt thereof, wherein the SVHD patient is in need of udenafil treatment,the method comprising: administering an effective amount of udenafil, ora pharmaceutically acceptable salt thereof, to the SVHD patient.
 32. Themethod of claim 31, wherein the SVHD patient is at least 12 years old.33. The method of claim 31, wherein the SVHD patient is a female. 34.The method of claim 32, wherein the SVHD patient is a female.
 35. Themethod of claim 31, wherein the SVHD patient is a male.
 36. The methodof claim 32, wherein the SVHD patient is a male.
 37. The method of claim31, wherein the udenafil, or a pharmaceutically acceptable salt thereof,is formulated as an oral dosage form.
 38. The method of claim 37,wherein the oral dosage form is a tablet.
 39. The method of claim 37,wherein the oral dosage form is a solid or semi-solid oral dosage formselected from a group of solid or semi-solid oral dosage formsconsisting of a tablet, a capsule, a gel, a liquid dispersion, a pill, apowder, and a suspension.
 40. A method of daily treating a singleventricle heart disease (SVHD) patient with udenafil, or apharmaceutically acceptable salt thereof, wherein the SVHD patient hasthe superior and inferior vena cavae attached to the pulmonary arteriesand is in need of udenafil treatment, the method comprising:administering an effective amount of udenafil, or a pharmaceuticallyacceptable salt thereof, to the SVHD patient to treat the SVHD patientin accordance with a daily treatment regimen.
 41. The method of claim40, wherein the SVHD patient is at least 12 years old.
 42. The method ofclaim 40, wherein the SVHD patient is a female.
 43. The method of claim41, wherein the SVHD patient is a female.
 44. The method of claim 40,wherein the SVHD patient is a male.
 45. The method of claim 41, whereinthe SVHD patient is a male.
 46. The method of claim 40, wherein theudenafil, or a pharmaceutically acceptable salt thereof, is formulatedas an oral dosage form.
 47. The method of claim 46, wherein the oraldosage form is a tablet.
 48. The method of claim 46, wherein the oraldosage form is a solid or semi-solid oral dosage form selected from agroup of solid or semi-solid oral dosage forms consisting of a tablet, acapsule, a gel, a liquid dispersion, a pill, a powder, and a suspension.49. A method of daily treating a single ventricle heart disease (SVHD)patient with udenafil, or a pharmaceutically acceptable salt thereof,wherein the SVHD patient has Fontan physiology and who is in need ofudenafil treatment, the method comprising: administering an effectiveamount of udenafil, or a pharmaceutically acceptable salt thereof, tothe SVHD patient to treat the SVHD patient in accordance with a dailytreatment regimen.
 50. The method of claim 49, wherein the SVHD patientis at least 12 years old.
 51. The method of claim 49, wherein the SVHDpatient is a female.
 52. The method of claim 50, wherein the SVHDpatient is a female.
 53. The method of claim 49, wherein the SVHDpatient is a male.
 54. The method of claim 50, wherein the SVHD patientis a male.
 55. The method of claim 49, wherein the udenafil, or apharmaceutically acceptable salt thereof, is formulated as an oraldosage form.
 56. The method of claim 55, wherein the oral dosage form isa tablet.
 57. The method of claim 55, wherein the oral dosage form is asolid or semi-solid oral dosage form selected from a group of solid orsemi-solid oral dosage forms consisting of a tablet, a capsule, a gel, aliquid dispersion, a pill, a powder, and a suspension.
 58. A method oftreating a Fontan patient who has undergone a Fontan procedure and whohas Fontan physiology in the management of a single ventricle heartdefect (SVHD), wherein the Fontan patient is in need of treatment forSVHD, the method comprising: administering an effective amount ofudenafil, or a pharmaceutically acceptable salt thereof, to the Fontanpatient to manage the Fontan patient's SVHD in accordance with atreatment regimen.
 59. The method of claim 58, wherein the Fontanpatient is at least 12 years old.
 60. The method of claim 58, whereinthe Fontan patient is a female.
 61. The method of claim 59, wherein theFontan patient is a female.
 62. The method of claim 58, wherein theFontan patient is a male.
 63. The method of claim 59, wherein the Fontanpatient is a male.
 64. The method of claim 58, wherein the udenafil, ora pharmaceutically acceptable salt thereof, is formulated as an oraldosage form.
 65. The method of claim 64, wherein the oral dosage form isa tablet.
 66. The method of claim 64, wherein the oral dosage form is asolid or semi-solid oral dosage form selected from a group of solid orsemi-solid oral dosage forms consisting of a tablet, a capsule, a gel, aliquid dispersion, a pill, a powder, and a suspension.
 67. Use of aneffective dose of udenafil, or a pharmaceutically acceptable saltthereof in the manufacture of a medicament for the treatment of a humanpatient, who has undergone Fontan palliation for improving the humanpatient's exercise capacity, wherein the human patient's exercisecapacity is adversely affected due to a decline in the human patient'smyocardial function after the Fontan palliation, wherein the humanpatient is in need of treatment to improve the human patient's exercisecapacity, and wherein the medicament is formulated for administrationwith an effective dose of udenafil, or a pharmaceutically acceptablesalt thereof.
 68. The use of claim 67, wherein the effective dose ofudenafil, or a pharmaceutically acceptable salt thereof, is about 87.5mg, and wherein the medicament is formulated as an oral dosage.
 69. Theuse of claim 67, wherein the effective dose of udenafil, or apharmaceutically acceptable salt thereof, is in a range of between about87.5 mg and about 175 mg, and wherein the medicament is formulated as anoral dosage.
 70. The use of claim 67, wherein the human patient hassingle ventricle heart disease.
 71. The use of claim 67, wherein thehuman patient has single ventricle heart disease, and wherein themedicament is formulated as an oral dosage form.
 72. The use of claim68, wherein the oral dosage form is a tablet.
 73. The use of claim 69,wherein the oral dosage form is a tablet.
 74. The use of claim 71,wherein the oral dosage form is a tablet.
 75. The use of claim 68,wherein the oral dosage form is a solid or semi-solid oral dosage formselected from a group of solid or semi-solid oral dosage formsconsisting of a tablet, a capsule, a gel, a liquid dispersion, a pill, apowder, and a suspension.
 76. The use of claim 69, wherein the oraldosage form is a solid or semi-solid oral dosage form selected from agroup of solid or semi-solid oral dosage forms consisting of a tablet, acapsule, a gel, a liquid dispersion, a pill, a powder, and a suspension.77. The use of claim 71, wherein the oral dosage form is a solid orsemi-solid oral dosage form selected from a group of solid or semi-solidoral dosage forms consisting of a tablet, a capsule, a gel, a liquiddispersion, a pill, a powder, and a suspension.
 78. The use of claim 67,wherein the human patient is a female patient.
 79. The use of claim 67,wherein the human patient is a male patient.
 80. Use of an effectivedose of udenafil, or a pharmaceutically acceptable salt thereof in themanufacture of a medicament for the treat of a human patient, who hasundergone Fontan palliation, for improving the human patient's exercisecapacity, whose exercise capacity is adversely affected due to a declinein the human patient's heart function after Fontan palliation, whereinthe human patient is in need of treatment to improve the human patient'sexercise capacity as determined by maximum oxygen uptake a maximumexercise output (VO₂ measurement), and wherein the medicament isformulated for administration of a total daily dose of udenafil, or apharmaceutically acceptable salt thereof, from about 125 mg to about 175mg.
 81. The use of claim 80, wherein the effective dose of udenafil, ora pharmaceutically acceptable salt thereof, is about 87.5 mg, andwherein the medicament is formulated as an oral dosage form for twicedaily administration.
 82. The use of claim 81, wherein the human patienthas single ventricle heart disease.
 83. The use of claim 82, wherein thehuman patient is at least about 12 years old.
 84. The use of claim 81,wherein the oral dosage form is a tablet.
 85. The use of claim 81,wherein the oral dosage form is a solid or semi-solid oral dosage formselected from a group of solid or semi-solid oral dosage formsconsisting of a tablet, a capsule, a gel, a liquid dispersion, a pill, apowder, and a suspension.
 86. The use of claim 82, wherein the oraldosage form is a tablet.
 87. The use of claim 82, wherein the oraldosage form is a solid or semi-solid oral dosage form selected from agroup of solid or semi-solid oral dosage forms consisting of a tablet, acapsule, a gel, a liquid dispersion, a pill, a powder, and a suspension.88. The use of claim 80, wherein the human patient has single ventricleheart disease.
 89. The use of claim 86, wherein the medicament is anoral dosage form.
 90. The use of claim 87, wherein the oral dosage formis a tablet.
 91. The use of claim 87, wherein the oral dosage form is asolid or semi-solid oral dosage form selected from a group of solid orsemi-solid oral dosage forms consisting of a tablet, a capsule, a gel, aliquid dispersion, a pill, a powder, and a suspension.
 92. The use ofclaim 88, wherein the human patient is at least about 12 years old. 93.The use of claim 92, wherein the medicament is an oral dosage form. 94.The use of claim 92, wherein the oral dosage form is a tablet.
 95. Theuse of claim 92, wherein the oral dosage form is a solid or semi-solidoral dosage form selected from a group of solid or semi-solid oraldosage forms consisting of a tablet, a capsule, a gel, a liquiddispersion, a pill, a powder, and a suspension.
 96. The use of claim 80,wherein the human patient is at least about 12 years old.
 97. The use ofclaim 96, wherein the medicament is an oral dosage form.
 98. The use ofclaim 97, wherein the oral dosage form is a tablet.
 99. The use of claim97, wherein the oral dosage form is a solid or semi-solid oral dosageform selected from a group of solid or semi-solid oral dosage formsconsisting of a tablet, a capsule, a gel, a liquid dispersion, a pill, apowder, and a suspension.
 100. The use of claim 80, wherein themedicament is formulated as an oral dosage form.
 101. The use of claim100, wherein the oral dosage form is a tablet.
 102. The use of claim100, wherein the oral dosage form is a solid or semi-solid oral dosageform selected from a group of solid or semi-solid oral dosage formsconsisting of a tablet, a capsule, a gel, a liquid dispersion, a pill, apowder, and a suspension.
 103. The use claim 80, wherein the humanpatient is a female.
 104. The use claim 80, wherein the human patient isa male.
 105. A method of treating a single ventricle heart disease(SVHD) patient with udenafil, or a pharmaceutically acceptable saltthereof, wherein the SVHD patient has undergone Fontan palliation andwhose exercise capacity has been adversely affected due to a decline inthe SVHD patient's myocardial function after the Fontan palliation, andwherein the SVHD patient is in need of treatment to improve the SVHDpatient's exercise capacity, said method comprising: administering tothe SVHD patient and whose exercise capacity has been adversely affecteddue to a decline in the SVHD patient's myocardial function after theFontan palliation with an effective daily dose of udenafil, or apharmaceutically acceptable salt thereof, to treat the SVHD patient.106. The method of claim 105, wherein the effective dose of udenafil, ora pharmaceutically acceptable salt thereof, is about 87.5 mg, andwherein the udenafil, or a pharmaceutically acceptable salt thereof, isformulated as an oral dosage.
 107. The method of claim 105, wherein theeffective dose of udenafil, or a pharmaceutically acceptable saltthereof, is about 125 mg, and wherein the udenafil, or apharmaceutically acceptable salt thereof, is formulated as an oraldosage.
 108. The use of claim 105, wherein the effective dose ofudenafil, or a pharmaceutically acceptable salt thereof, is in a rangeof between about 87.5 mg and about 175 mg, and wherein the udenafil, ora pharmaceutically acceptable salt thereof, is formulated as an oraldosage.
 109. The use of claim 105, wherein the SVHD patient was bornwith single ventricle heart disease, and wherein the udenafil, or apharmaceutically acceptable salt thereof, is formulated as an oraldosage.
 110. The use of claim 105, wherein the udenafil, or apharmaceutically acceptable salt thereof, is formulated as an oraldosage form.
 111. The method of claim 106, wherein the oral dosage formis a tablet.
 112. The method of claim 107, wherein the oral dosage formis a tablet.
 113. The method of claim 108, wherein the oral dosage formis a tablet.
 114. The method of claim 109, wherein the oral dosage formis a tablet.
 115. The method of claim 110, wherein the oral dosage formis a tablet.
 116. The method of claim 106, wherein the oral dosage formis a solid or semi-solid oral dosage form selected from a group of solidor semi-solid oral dosage forms consisting of a tablet, a capsule, agel, a liquid dispersion, a pill, a powder, and a suspension.
 117. Themethod of claim 107, wherein the oral dosage form is a solid orsemi-solid oral dosage form selected from a group of solid or semi-solidoral dosage forms consisting of a tablet, a capsule, a gel, a liquiddispersion, a pill, a powder, and a suspension.
 118. The method of claim108, wherein the oral dosage form is a solid or semi-solid oral dosageform selected from a group of solid or semi-solid oral dosage formsconsisting of a tablet, a capsule, a gel, a liquid dispersion, a pill, apowder, and a suspension.
 119. The method of claim 109, wherein the oraldosage form is a solid or semi-solid oral dosage form selected from agroup of solid or semi-solid oral dosage forms consisting of a tablet, acapsule, a gel, a liquid dispersion, a pill, a powder, and a suspension.120. The method of claim 110, wherein the oral dosage form is a solid orsemi-solid oral dosage form selected from a group of solid or semi-solidoral dosage forms consisting of a tablet, a capsule, a gel, a liquiddispersion, a pill, a powder, and a suspension.
 121. The use of claim106, wherein the SVHD patient is a female SVHD patient.
 122. The use ofclaim 106, wherein the SVHD patient is a male SVHD patient.
 123. The useof claim 107, wherein the SVHD patient is a female SVHD patient. 124.The use of claim 107, wherein the SVHD patient is a male SVHD patient.125. The use of claim 108, wherein the SVHD patient is a female SVHDpatient.
 126. The use of claim 108, wherein the SVHD patient is a maleSVHD patient.
 127. The use of claim 109, wherein the SVHD patient is afemale SVHD patient.
 128. The use of claim 109, wherein the SVHD patientis a male SVHD patient.
 129. The use of claim 110, wherein the SVHDpatient is a female SVHD patient.
 130. The use of claim 110, wherein theSVHD patient is a male SVHD patient.
 131. The use of claim 111, whereinthe SVHD patient is a female SVHD patient.
 132. The use of claim 111,wherein the SVHD patient is a male SVHD patient.
 133. The use of claim112, wherein the SVHD patient is a female SVHD patient.
 134. The use ofclaim 112, wherein the SVHD patient is a male SVHD patient.
 135. The useof claim 113, wherein the SVHD patient is a female SVHD patient. 136.The use of claim 113, wherein the SVHD patient is a male SVHD patient.137. The use of claim 114, wherein the SVHD patient is a female SVHDpatient.
 138. The use of claim 114, wherein the SVHD patient is a maleSVHD patient.
 139. The use of claim 115, wherein the SVHD patient is afemale SVHD patient.
 140. The use of claim 115, wherein the SVHD patientis a male SVHD patient.
 141. The use of claim 116, wherein the SVHDpatient is a female SVHD patient.
 142. The use of claim 116, wherein theSVHD patient is a male SVHD patient.
 143. A method of treating a humanpatient who has had a Fontan procedure for improving the patient'sexercise capacity, wherein the human patient is in need of treatment toimprove the patient's exercise capacity, the method comprisingadministering to the human patient who has undergone the Fontanprocedure an effective amount of udenafil, or a pharmaceuticallyacceptable salt thereof, to improve the patient's exercise capacity.144. The method of claim 143, wherein the human patient is at least 12years old.
 145. The method of claim 143, wherein the human patient is afemale.
 146. The method of claim 143, wherein the human patient is amale.
 147. The method of claim 143, wherein the udenafil, or apharmaceutically acceptable salt thereof, is formulated as an oraldosage form.
 148. The method of claim 147, wherein the oral dosage formis a tablet.
 149. The method of claim 147, wherein the oral dosage formis a solid or semi-solid oral dosage form selected from a group of solidor semi-solid oral dosage forms consisting of a tablet, a capsule, agel, a liquid dispersion, a pill, a powder, and a suspension.